A brief agitation rating scale (BARS) for nursing home elderly

Cannabidiol as a Treatment for Neurobiological, Behavioral, and Psychological Symptoms in Early-Stage Dementia: A Double-Blind, Placebo-Controlled Clinical Trial Protocol

Rationale: The slowing of disease progression in dementia in the early stages of diagnosis is paramount to improving the quality of life for those diagnosed and their support networks. Accumulating evidence suggests that CBD, a constituent of Cannabis sativa, is associated with neuroprotective, neuroendocrine, and psychotherapeutic effects, suggesting that it may be beneficial to dementia treatment. However, no published human study to date has examined this possibility. This trial aims to determine whether daily treatment with CBD over a 12-week period is associated with improved neurobiological, behavioral, and psychological outcomes in individuals living with early-stage dementia. Methods: Sixty participants with early-stage dementia will be recruited for a randomized, double-blind, placebo-controlled clinical trial. Participants will be randomized into either 99.9% pure CBD or placebo treatment conditions and administered two capsules per day for 12 weeks. Participants will commence a 200 mg/day dose for 2 weeks before escalating to 300 mg/day for the remaining 10 weeks. Neuroimaging and blood-based neuroendocrine profiles will be assessed at baseline and post-treatment. Psychological and behavioral symptoms will be assessed at baseline, 6 weeks, and post-treatment. Monitoring of health and side-effects will be conducted through weekly home visits. Discussion: This study is among the first to investigate the effects of isolated CBD in improving neuroanatomical and neuroendocrine changes, alongside psychological symptoms, during the early stages of dementia diagnosis. The outcomes of this trial have the capacity to inform a potential novel and accessible treatment approach for individuals living with early-stage dementia, and in turn, improve quality of life, prognoses, and treatment outcomes. Trial Registration: This trial has been registered with the Therapeutic Goods Administration (CT-2020-CTN-03849-1v2) and the Australian and New Zealand Clinical Trials Registry (ACTRN12621001364864).

The short-term effect of a modified comprehensive geriatric assessment and regularly case conferencing on neuropsychiatric symptoms in nursing homes: a cluster randomized trial

Aims

To investigate the short-term effect of implementing a modified comprehensive geriatric assessment and regularly case conferencing in nursing homes on neuropsychiatric symptoms.

Background

Neuropsychiatric symptoms are common and may persist over time in nursing home residents. Evidence of effective interventions is scarce.

Design

A parallel cluster-randomised controlled trial.

Methods

The intervention was monthly standardised case conferencing in combination with a modified comprehensive geriatric assessment. The control group received care as usual.

Main outcome measure.

The total score on the short version of the Neuropsychiatric Inventory (NPI-Q, 12-items).

Results

A total of 309 residents at 34 long-term care wards in 17 nursing homes (unit of randomisation) were included. The intervention care units conducted on average two case conference-meetings (range 1–3), discussing a mean of 4.8 (range 1–8) residents. After 3 months, there were no difference of NPI-Q total score between the intervention (-0.4) and the control group (0.5) (estimated mean difference = -1.0, 95% CI -2.4 to 0.5, p = 0.19). There was a difference in favour of the intervention group on one of the secondary outcome measures, the apathy symptoms (-0.5 95% CI: -0.9 to -0.1, p = 0.03).

Conclusion

In this study there were no short-term effect of case conferencing and modified comprehensive geriatric assessments after three months on the total score on neuropsychiatric symptoms. The intervention group had less apathy at 3 months follow-up compared to those receiving care as usual. The findings suggest that a more comprehensive intervention is needed to improve the total Neuropsychiatric symptoms burden and complex symptoms.

Trial registration

Due to delays in the organisation, the study was registered after study start, i.e. retrospectively in Clinicaltrials.gov # NCT02790372 at https://clinicaltrials.gov/; Date of clinical trial registration: 03/06/2016.

Effects on sleep from group activity with a robotic seal for nursing home residents with dementia: a cluster randomized controlled trial

OBJECTIVES

Sleep disturbances are common in people with dementia and increase with the severity of the disease. Sleep disturbances are complex and caused by several factors and are difficult to treat. There is a need for more robust and systematic studies dealing with sleep disturbances in older people with dementia. The aim of this study was to investigate effects from robot-assisted (Paro) group activity on sleep patterns in nursing home (NH) residents with dementia.

DESIGN

A cluster randomized controlled trial.

SETTING

Special care units in 10 NH in Norway.

PARTICIPANTS

A total of 60 participants over 65 years with dementia were recruited. Thirty participants were recruited to the intervention group and 30 participants to the control group.

INTERVENTION

Participants participated in group activity with Paro for 30 minutes twice a week over 12 weeks or in control group (treatment as usual).

MEASUREMENTS

Sleep-wake patterns were assessed objectively by 7 days of wrist actigraphy before and after the intervention. Data were collected between March 2013 and September 2014. Data were analyzed using mixed models.

RESULTS

Positive effects on change in sleep were found in the intervention group as compared with the control group. The intervention group increased percentage of sleep efficiency, increased the amount of total sleep time and reduced number of nocturnal awakenings. In addition, a significant effect was found in reduced awakenings after sleep onset.

CONCLUSIONS

Social stimulation through engaging group activity could contribute to improved sleep in people with dementia in NH. Increased sleep efficiency and total sleep time, in addition to fewer night awakenings, affect central indicators of good sleep quality across the life span. Improved sleep quality will also affect quality of life and comorbidities in vulnerable groups. We believe group activity with Paro to be an accessible and feasible non-pharmacological treatment for those who enjoy Paro.

Emerging topics in dementia care and services

BACKGROUND

The National Institute on Aging (NIA), in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act (NAPA), convened a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series. This review article summarizes three areas of emerging science that are likely to grow in importance given advances in measurement, technologies, and diagnostic tests that were presented at the Summit.

RESULTS

Dr. Cassel discussed novel ethical considerations that have resulted from scientific advances that have enabled early diagnosis of pre-clinical dementia. Dr. Monin then summarized issues regarding emotional experiences in persons with dementia and their caregivers and care partners, including the protective impact of positive emotion and heterogeneity of differences in emotion by dementia type and individual characteristics that affect emotional processes with disease progression. Finally, Dr. Jared Benge provided an overview of the role of technologies in buffering the impact of cognitive change on real-world functioning and their utility in safety and monitoring of function and treatment adherence, facilitating communication and transportation, and increasing access to specialists in underserved or remote areas.

CONCLUSIONS

National policy initiatives, supported by strong advocacy and increased federal investments, have accelerated the pace of scientific inquiry and innovation related to dementia care and services but have raised some new concerns regarding ethics, disparities, and attending to individual needs, capabilities, and preferences.

Brief Self-Report Measure of Agitation: A Psychometric Investigation in a German Sample

To perform repeated measurements in clinical practice without putting unnecessary strain on patients, short instruments are needed. The Brief Self-Report Measure of Agitation (BAM) is a short measure assessing agitation, which has been associated with suicidal ideation and behavior. However, its reliability and validity have not been examined in an independent sample. A non-clinical sample of N = 429 participants aged between 18-81 (M = 27.36, SD = 9.67; 82.3% female) was surveyed online. A confirmatory factor analysis was conducted and reliability was investigated. The validity of the BAM was examined by calculating correlations and an ANOVA for differences in BAM scores between subgroups. BAM items significantly loaded onto one factor (factor loadings: ≥ .62) and the measure was found to have good reliability (Cronbach's α = .83) and convergent/discriminant validity. Participants with recent suicidal ideation and those with recent suicidal ideation and lifetime suicide attempts had significantly higher BAM scores than participants without suicidal ideation/suicide attempt. Results indicate good validity and reliability for the measurement of agitation with the German version of the BAM in the present sample. Thereby, we introduce a brief instrument in German for repeated assessment of agitation in research and clinical practice.

Agitation and impulsivity in mid and late life as possible risk markers for incident dementia

To identify knowledge gaps regarding new-onset agitation and impulsivity prior to onset of cognitive impairment or dementia the International Society to Advance Alzheimer's Research and Treatment Neuropsychiatric Syndromes (NPS) Professional Interest Area conducted a scoping review. Extending a series of reviews exploring the pre-dementia risk syndrome Mild Behavioral Impairment (MBI), we focused on late-onset agitation and impulsivity (the MBI impulse dyscontrol domain) and risk of incident cognitive decline and dementia. This scoping review of agitation and impulsivity pre-dementia syndromes summarizes the current biomedical literature in terms of epidemiology, diagnosis and measurement, neurobiology, neuroimaging, biomarkers, course and prognosis, treatment, and ongoing clinical trials. Validations for pre-dementia scales such as the MBI Checklist, and incorporation into longitudinal and intervention trials, are needed to better understand impulse dyscontrol as a risk factor for mild cognitive impairment and dementia.

A review of measures of three common dementia-related behaviors: Rejection of care, aggression, and agitation

BACKGROUND

Clustering of behavioral symptoms in dementia is common in dementia scales. However, lack of distinction may have negative treatment implications when a treatment response differs depending on classification of behaviors. Historically, rejection of care, aggression, and agitation have been lumped together. Yet, several studies have indicated these may be conceptually different behaviors.

OBJECTIVE

To examine how rejection of care, aggression, and agitation are described and operationalized in existing measures of dementia-related behaviors.

METHOD

We identified instruments developed to measure behavioral symptoms of dementia from two existing systematic reviews. Additionally, we conducted a literature review of peer-reviewed articles published from 1980 to 2017 to identify measures that were not captured in the two previous reviews.

RESULTS

43 instruments developed to measure behavioral symptoms of dementia were examined. Of these, 25 (58.1%) included items related to rejection of care; 32 (74.4%) included items related to aggression; and 35 (81.4%) included agitation items. Descriptions of these behaviors were highly variable across the instruments.

CONCLUSIONS

The review demonstrated that rejection, aggression, and agitation are measured in most scales, yet their operationalization is highly variable, and they are not typically distinguished from each other. Future efforts should be directed at developing uniform terminology to describe dementia-related behaviors while distinguishing rejection of care, aggression, and agitation in dementia scales.

Review of outcome measures in PARO robot intervention studies for dementia care

The aim of this study was to describe interventions for PARO, as well as the outcomes evaluated and found following use of PARO, and to identify outcome measures in PARO intervention studies for older adults with dementia. Multiple databases (Web of Science, PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Cochrane, and Scopus) were searched and eight studies were included in the systematic review. The review demonstrated that interventions using PARO can be beneficial for improving QOL, affect, social interaction, and reducing NPS and psychotropic or pain medication use. This study identified three domains of outcome measures used to assess the effects of interventions using the PARO robot: quality of life, biological and physiological conditions, and medical treatment.

Do Warmed Blankets Change Pain, Agitation, Mood or Analgesic Use Among Nursing Home Residents?

BACKGROUND

Pain, agitation, and thermal discomfort are common symptoms of older adults residing in nursing homes. Nonpharmacologic interventions are recognized as a best practice strategy for people living in nursing homes because of their low adverse effect profile and increased evidence of effectiveness. Warmed blankets have not been empirically tested for use in long-term care.

AIMS

The purpose of this quality improvement project was to describe the use of warmed blankets in a nursing home setting and determine if use was associated with changes in pain, agitation, mood, or analgesic use.

DESIGN

A pretest posttest design was used along with a comparison of intact groups.

SETTINGS

The setting was one 160-bed skilled long-term care facility.

PARTICIPANTS/SUBJECTS

There were 141 residents eligible since they did not have a condition that could be worsened by superficial heat.

METHODS

Warmed blankets were unfolded and placed over residents with pain, agitation, or thermal discomfort. Short-term pain measures included use of the Revised FACES Pain Scale, the PAINAD (Pain Assessment in Advanced Dementia) scale, and the Brief Agitation Rating Scale. Long-term measures were taken from the electronic medical record.

RESULTS

Of the 141 eligible residents, 24.1% (n = 34) received a warmed blanket over the 1- month study period. There were statistically significant decreases in both pain level and agitation among baseline, 20 minutes after application, and the subsequent shift assessments (p < .001). There were also long-term changes in the number of pain complaints (p = .040), severity of pain complaints (p = .009), and as-needed analgesic use (p = .011). There were no statistically significant differences between the treated group and comparison group on any long-term measures.

CONCLUSIONS

Warmed blankets are a low-cost intervention with a high potential for bringing comfort to nursing home residents.

EEG Data Collection in Children with ASD: The Role of State in Data Quality and Spectral Power

BACKGROUND

Electroencephalography can elucidate neurobiological mechanisms underlying heterogeneity in ASD. Studying the full range of children with ASD introduces methodological challenges stemming from participants' difficulties tolerating the data collection process, leading to diminished EEGdataretentionandincreasedvariabilityin participant 'state' during the recording. Quantifying state will improve data collection methods and aide in interpreting results.

OBJECTIVES

Observationally quantify participant state during the EEG recording; examine its relationship to child characteristics, data retention and spectral power.

METHODS

Participants included 5-11 year-old children with D (N=39) and age-matched TD children (N=16). Participants were acclimated to the EEG environment using behavioral strategies. EEG was recorded while participants watched a video of bubbles. Participant 'state' was rated using a Likert scale (Perceived State Rating: PSR).

RESULTS

Participants with ASD had more elevated PSR than TD participants. Less EEG data were retained in participants with higher PSR scores, but this was not related to age or IQ. TD participants had higher alpha power compared with the ASD group. Within the ASD group, participants with high PSR had decreased frontal alpha power.

CONCLUSIONS

Given supportive strategies, EEG data was collected from children with ASD across cognitive levels. Participant state influenced both EEG data retention and alpha spectral power. Alpha suppression is linked to attention and vigilance, suggesting that these participants were less 'at rest'. This highlights the importance of considering state when conducting EEG studies with challenging participants, both to increase data retention rates and to quantify the influence of state on EEG variables.

Aggressive behaviour risk assessment tool for long-term care (ABRAT-L): Validation study

This prospective cohort study was conducted to validate the usefulness of the Aggressive Behaviour Risk Assessment Tool for Long-Term Care (ABRAT-L) in predicting aggressive events. A total of 615 newly admitted residents at 22 long-term care homes in Canada were included. The risk of aggression was assessed using the six-item ABRAT-L within 24 hours of admission, and incident reports of aggressive events occurring within 30 days of admission were collected. Forty-seven residents out of 615 had one or more aggressive events (7.6%). The receiver operating characteristics analysis of ABRAT-L showed a good discriminant ability at the previously recommended cut-off score of 4, with satisfactory sensitivity and specificity. The usefulness of ABRAT-L in identifying potentially aggressive residents at the time of admission was confirmed. This validation study supports the adoption of a proactive risk assessment tool, ABRAT-L, as a part of routine admission assessments at long-term care homes.

Study protocol: A Montessori approach to dementia-related, non-residential respite services in Australia

Given the social burden and significant cost of dementia care in Australia, finding evidence-based approaches that improve outcomes, maintain independence, and reduce the impact on patients and families is essential. Finding effective ways to train and assist the healthcare staff who support these individuals is also critical, as they are considered to be at risk of workplace stress, burnout, and other psychological disturbances which negatively affects standards of care. The current paper describes a protocol for evaluating the effects of a Montessori-based approach to dementia care, in non-residential respite centres. An 18 month prospective observational, cohort controlled design is suggested that will compare participants from a community respite service that has undergone a Montessori-based workplace culture change and those from a service that provides a person-centred 'care as usual' approach. To achieve this, the protocol includes the assessment of participants across multiple variables on a monthly basis including the cognitive, behavioural, and emotional functioning of clients with dementia, levels of caregiver burden experienced by informal carers, and burnout, compassion satisfaction and workplace engagement among respite staff. The protocol also employs a qualitative evaluation of program fidelity. This approach will provide further insight into the potential benefits of early intervention with Montessori approaches for persons living with dementia in the community, their caregivers, and the staff and volunteers who assist them.

Aggressive Behaviour Risk Assessment Tool for newly admitted residents of long-term care homes

AIM

The aim of this study was to revise the 10-item Aggressive Behaviour Risk Assessment Tool for predicting aggressive events among residents newly admitted to long-term care homes.

BACKGROUND

The original tool had acceptable sensitivity and specificity for identifying potentially aggressive patients in acute care medical-surgical units, but its usefulness in long-term care homes is unknown.

DESIGN

A retrospective cohort study design was used.

METHODS

All residents admitted to 25 long-term care homes in western Canada were assessed for the risk of aggression using the original tool within 24 hours of admission from January 2014 - December 2014 (n = 724). Incident reports of aggressive events occurring within 30 days of admission were collected. Multiple logistic regression and receiver operating characteristics analyses were performed.

RESULTS

Fifty-three residents of 724 exhibited aggressive behaviours. The demographic variable of age less than 85 years was found to be a positive predictor of aggressive events in multivariate logistic regression model and was added to the tool. The revised six-item Aggressive Behaviour Risk Assessment Tool for Long-Term Care consists of one new item, age less than 85 years and five items from the original tool: History of physical aggression, physically aggressive/threatening, anxiety, confusion/cognitive impairment and threatening to leave. The receiver operating characteristics of the revised tool with weighted scoring showed a good discriminant ability with satisfactory sensitivity and specificity at the recommended cut-off score of 4.

CONCLUSION

The revised six-item tool may be useful in identifying potentially aggressive residents newly admitted to long-term care homes.

Effect of animal-assisted interventions on depression, agitation and quality of life in nursing home residents suffering from cognitive impairment or dementia: a cluster randomized controlled trial

OBJECTIVES

The prevalence of neuropsychiatric symptoms in cognitively impaired nursing home residents is known to be very high, with depression and agitation being the most common symptoms. The possible effects of a 12-week intervention with animal-assisted activities (AAA) in nursing homes were studied. The primary outcomes related to depression, agitation and quality of life (QoL).

METHOD

A prospective, cluster randomized multicentre trial with a follow-up measurement 3 months after end of intervention was used. Inclusion criteria were men and women aged 65 years or older, with a diagnosis of dementia or having a cognitive deficit. Ten nursing homes were randomized to either AAA with a dog or a control group with treatment as usual. In total, 58 participants were recruited: 28 in the intervention group and 30 in the control group. The intervention consisted of a 30-min session with AAA twice weekly for 12 weeks in groups of three to six participants, led by a qualified dog handler. Norwegian versions of the Cornell Scale for Depression, the Brief Agitation Rating Scale and the Quality of Life in Late-stage Dementia scale were used.

RESULTS

A significant effect on depression and QoL was found for participants with severe dementia at follow-up. For QoL, a significant effect of AAA was also found immediately after the intervention. No effects on agitation were found.

CONCLUSIONS

Animal-assisted activities may have a positive effect on symptoms of depression and QoL in older people with dementia, especially those in a late stage. Copyright © 2016 John Wiley & Sons, Ltd.

Change in quality of life in older people with dementia participating in Paro-activity: a cluster-randomized controlled trial

AIM

The aim of this study was to investigate effects of robot-assisted group activity with Paro on quality of life in older people with dementia.

BACKGROUND

Nursing home residents with severe dementia often experience social withdrawal and lower quality of life, which are suggested to be enhanced by non-pharmacological interventions.

DESIGN

A cluster-randomized controlled trial. Ten nursing home units were randomized to robot-assisted intervention or control group (treatment as usual).

METHODS

Data were collected between March 2013-September 2014. 27 participants participated in group activity for 30 minutes twice a week over 12 weeks, 26 participated in the control group. Change in quality of life was assessed by local nurses through the Quality of Life in Late-Stage Dementia scale at baseline, after end of intervention and at 3 months follow-up. The scale and regular psychotropic medication were analysed stratified by dementia severity. Analysis using mixed model, one-way anova and linear regression were performed.

RESULTS

An effect was found among participants with severe dementia from baseline to follow-up showing stable quality of life in the intervention group compared with a decrease in the control group. The intervention explained most of the variance in change in the total scale and in the subscales describing Tension and Well-being for the group with severe dementia. The intervention group used significantly less psychotropic medication compared with the control group after end of intervention.

CONCLUSION

Pleasant and engaging activities facilitated by nursing staff, such as group activity with Paro, could improve quality of life in people with severe dementia. The trial is in adherence with the CONSORT statement and is registered at www.clinicaltrials.gov (study ID number: NCT01998490) [corrected].

Cortisol and Wake Time in Nursing Home Residents With Behavioral Symptoms of Dementia

Alterations in sleep and behavioral symptoms are consistently reported among nursing home residents with dementia. Disregulation in the hypothalamic-pituitary-adrenal axis (HPA), indexed by basal cortisol levels, offers one explanation. The purpose of this study is to examine the relationship between wake time and cortisol slope in residents with behavioral symptoms. The study included 27 residents aged 71 to 84 years with dementia and behavioral symptoms. Using a within-subject longitudinal design, the researchers documented wake time and collected saliva samples for 4 consecutive days upon waking and at 30 min, 6 hr, and 12 hr after waking. Within-person cortisol slopes were categorized into zero-positive and negative slopes. The zero—positives (35%) exhibited an earlier wake time than the negatives (65%). These preliminary results suggest both a relationship between wake time and HPA diurnal profile and an association between the sleep-wake cycle and cortisol secretion among nursing home residents with dementia.

Pattern and correlates of agitation in an acute psychiatry in-patient setting in a teaching hospital

Agitation among psychiatry inpatients can be a distressing and burdensome entity for patients, caregivers and staff. It has been poorly studied in low-middle income countries such as India both within acute care as well as long stay settings. 272 psychiatry admissions had 19.9% prevalence of agitation with the most common form being non goal directed physical agitation (13.6%). Episodes of agitation were most likely to occur on the 3rd or 2nd day of admission. Substance abuse [O.R.=2.51(1.05-5.99)] and the presence of persecutory delusions [O.R.=2.62(1.34-5.15)] were independently associated with agitation. It is difficult to predict violence in acutely ill individuals and there is evidence that the emergence of more serious aggression may be preceded by milder forms of agitation. Therefore, there is a need to identify various forms of agitation and its correlates. An understanding of these factors may assist in planning appropriate interventions that could improve patient outcomes and reduce the burden on caregivers.

Optimizing Eating Performance for Long-Term Care Residents With Dementia: Testing the Impact of Function-Focused Care for Cognitively Impaired

OBJECTIVES

The objective of this study was to evaluate the impact of a well-developed theory-based function-focused care for cognitively impaired (FFC-CI) intervention on eating performance among long-term care (LTC) residents with moderate-to-severe cognitive impairment.

DESIGN

A secondary analysis of longitudinal data from 2 cluster-randomized controlled trials that originally tested the impact of FFC-CI on all function and physical activities.

PARTICIPANTS AND SETTING

Participants were 199 residents with moderate-to-severe cognitive impairment from 4 nursing homes and 4 assisted living facilities.

MEASUREMENTS

Data at baseline, and 3 and 6 months were used. Resident outcome data used in this analysis included eating performance conceptualized using the single self-care "feeding" item in the Barthel Index, cognitive function by Mini-Mental State Examination, sitting balance conceptualized using the single "chair sit-sitting balance" item in the Tinetti Gait and Balance scale, physical capability by Physical Capability Scale, depression by Cornell Scale for Depression in Dementia, and agitation by Cohen-Mansfield Agitation Inventory (short form).

RESULTS

At baseline, almost one-third (32.2%) of the 199 residents needed help with eating. There was no significant change with regard to eating performance over time in both groups, and no significant treatment by time difference between groups in eating performance (P = .195).

CONCLUSION

Current findings support a need to revise the FFC-CI to better address eating performance. Future work may benefit from a stronger focus on eating performance rather than the more commonly addressed functional tasks, such as bathing, dressing, and ambulation. In addition, the inclusion of a more heterogeneous group of LTC residents with regard to eating performance is needed to test the impact of the revised approach on eating performance.

The Use of Intercessory Prayer to Reduce Disruptive Behaviors of Patients With Dementia: A Pilot Feasibility Study

A prospective longitudinal design was used to identify the feasibility, and preliminary efficacy of 12 weeks of intercessory prayer to reduce the disruptive behaviors of six late-stage dementia patients. One group of Catholic nuns offered the Lord's Prayer for assigned patients twice a day. Intercessory prayer for the entire subject group was also offered, by a second group of nuns, via a Latria (modality) called "Perpetual Adoration." Disruptions were documented from 3 weeks preintervention to 3 weeks postintervention. Consents were received for two thirds of invited patients. Retention was reduced by the death of two patients. Fidelity, assessed by retrospective report, was maintained throughout the study. Use of off-label antipsychotic medications was reduced or discontinued in four patients during the trial. The repeated measures analysis of variance, while indicative of a trend, did not reach a level of significance, likely due to small sample size. However, the average effect on behavior resulted in a reduction of disruptive incidents, for the group, in approximately 27 behavior categories/week. This study suggests that it is feasible to improve the life quality of patients in the terminal phase of their illness through prayer reducing their need to respond to life in a disturbed manner.

Evaluation of a pet-assisted living intervention for improving functional status in assisted living residents with mild to moderate cognitive impairment: a pilot study

BACKGROUND

In older adults with cognitive impairment (CI), decreased functional status and increased behavioral symptoms require relocation from assisted living (AL) to nursing homes. Studies support positive effects of pets on health/function.

PURPOSE

Evaluate the effectiveness of the Pet AL (PAL) intervention to support physical, behavioral, and emotional function in AL residents with CI.

METHODS

Cognitively impaired AL residents randomized to 60-90 minute sessions [PAL (n = 22) or reminiscing (n = 18)] twice/week for 12 weeks. PAL interventionist encourages residents to perform skills with the visiting dog; reminiscing interventionist encourages residents to reminisce. Monthly assessment of physical (energy expenditure, activities of daily living), emotional (depression, apathy), and behavioral (agitation) function.

RESULTS

In linear mixed models, physical activity depressive symptoms improved more with PAL.

CONCLUSION

Evidence supports that the PAL program helps preserve/enhance function of AL residents with CI. Additional study is required to evaluate the duration and predictors of effectiveness of the PAL intervention.

Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures

BACKGROUND

Neuropsychiatric symptoms (NPS) occur in people with dementia throughout disease course and across etiologies. NPS are associated with significant morbidities and hastened disease processes. Nevertheless, people with dementia are not systematically assessed for NPS in clinical settings. We review existing NPS measures for clinical and/or research purposes, and identify measurement gaps.

METHODS

We conducted a computerized search of peer-reviewed published studies of measures (January 1, 1980-December 1, 2013) using multiple search terms. Measures selected for review were in English, had adequate psychometric properties, and were developed for or used with people with dementia. Papers describing measures were evaluated by three coders along seven characteristics: behavioral domains, number of items, method of administration, response categories, targeted population, setting, and psychometric properties.

RESULTS

Overall, 2,233 papers were identified through search terms, and 36 papers from manual searches of references. From 2,269 papers, 85 measures were identified of which 45 (52.9%) had adequate psychometric properties and were developed or used with dementia populations. Of these, 16 (35.6%) were general measures that included a wide range of behaviors; 29 (64.4%) targeted specific behaviors (e.g. agitation). Measures differed widely as to behaviors assessed and measurement properties.

CONCLUSIONS

A robust set of diverse measures exists for assessing NPS in different settings. No measures identify risk factors for behaviors or enable an evaluation of the context in which behaviors occur. To improve clinical efforts, research is needed to evaluate concordance of behavioral ratings between formal and informal caregivers, and to develop and test measures that can identify known risks for behaviors and the circumstances under which behaviors occur.

The effect of person-centred dementia care to prevent agitation and other neuropsychiatric symptoms and enhance quality of life in nursing home patients: a 10-month randomized controlled trial

AIMS

We examined whether Dementia Care Mapping (DCM) or the VIPS practice model (VPM) is more effective than education of the nursing home staff about dementia (control group) in reducing agitation and other neuropsychiatric symptoms as well as in enhancing the quality of life among nursing home patients.

METHODS

A 10-month three-armed cluster-randomized controlled trial compared DCM and VPM with control. Of 624 nursing home patients with dementia, 446 completed follow-up assessments. The primary outcome was the change on the Brief Agitation Rating Scale (BARS). Secondary outcomes were changes on the 10-item version of the Neuropsychiatric Inventory Questionnaire (NPI-Q), the Cornell Scale for Depression in Dementia (CSDD) and the Quality of Life in Late-Stage Dementia (QUALID) scale.

RESULTS

Changes in the BARS score did not differ significantly between the DCM and the control group or between the VPM and the control group after 10 months. Positive differences were found for changes in the secondary outcomes: the NPI-Q sum score as well as the subscales NPI-Q agitation and NPI-Q psychosis were in favour of both interventions versus control, the QUALID score was in favour of DCM versus control and the CSDD score was in favour of VPM versus control.

CONCLUSIONS

This study failed to find a significant effect of both interventions on the primary outcome. Positive effects on the secondary outcomes indicate that the methods merit further investigation.

Aromatherapy for dementia

BACKGROUND

Complementary therapy has received great interest within the field of dementia treatment and the use of aromatherapy and essential oils is increasing. In a growing population where the majority of patients are treated by US Food and Drug Administration (FDA)-approved drugs, the efficacy of treatment is short term and accompanied by negative side effects. Utilisation of complimentary therapies in dementia care settings presents as one of few options that are attractive to practitioners and families as patients often have reduced insight and ability to verbally communicate adverse reactions. Amongst the most distressing features of dementia are the behavioural and psychological symptoms. Addressing this facet has received particular interest in aromatherapy trials, with a shift in focus from reducing cognitive dysfunction to the reduction of behavioural and psychological symptoms in dementia.

OBJECTIVES

To assess the efficacy of aromatherapy as an intervention for people with dementia.

SEARCH METHODS

ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register, was searched on 26 November 2012 and 20 January 2013 using the terms: aromatherapy, lemon, lavender, rose, aroma, alternative therapies, complementary therapies, essential oils.

SELECTION CRITERIA

All relevant randomised controlled trials were considered. A minimum length of a trial and requirements for follow-up were not included, and participants in included studies had a diagnosis of dementia of any type and severity. The review considered all trials using fragrance from plants defined as aromatherapy as an intervention with people with dementia and all relevant outcomes were considered.

DATA COLLECTION AND ANALYSIS

Titles and abstracts extracted by the searches were screened for their eligibility for potential inclusion in the review. For Burns 2011, continuous outcomes were estimated as the mean difference between groups and its 95% confidence interval using a fixed-effect model. For Ballard 2002, analysis of co-variance was used for all outcomes, with the nursing home being treated as a random effect.

MAIN RESULTS

Seven studies with 428 participants were included in this review; only two of these had published usable results. Individual patient data were obtained from one trial (Ballard 2002) and additional analyses performed. The additional analyses conducted using individual patient data from Ballard 2002 revealed a statistically significant treatment effect in favour of the aromatherapy intervention on measures of agitation (n = 71, MD -11.1, 95% CI -19.9 to -2.2) and behavioural symptoms (n = 71, MD -15.8, 95% CI -24.4 to -7.2). Burns 2011, however, found no difference in agitation (n = 63, MD 0.00, 95% CI -1.36 to 1.36), behavioural symptoms (n = 63, MD 2.80, 95% CI -5.84 to 11.44), activities of daily living (n = 63, MD -0.50, 95% CI -1.79 to 0.79) and quality of life (n = 63, MD 19.00, 95% CI -23.12 to 61.12). Burns 2011 and Fu 2013 found no difference in adverse effects (n = 124, RR 0.97, 95% CI 0.15 to 6.46) when aromatherapy was compared to placebo.

AUTHORS' CONCLUSIONS

The benefits of aromatherapy for people with dementia are equivocal from the seven trials included in this review. It is important to note there were several methodological difficulties with the included studies. More well-designed, large-scale randomised controlled trials are needed before clear conclusions can be drawn regarding the effectiveness of aromatherapy for dementia. Additionally, several issues need to be addressed, such as whether different aromatherapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.

What is known about dementia care recipient violence and aggression against caregivers?

Aggression is a known behavior in dementia, but there is little in the literature about risk to home-based caregivers in situations where severe aggression is present. This article examines this issue with a focus on what is known and where further research is needed. Rates of severe aggression by dementia care recipients against caregivers are estimated at greater than 20%, and may be the strongest predictor of nursing home placement. Measures containing both assessment of behavior and objective measures of caregiver trauma are needed, along with interventions aimed at educating and protecting caregivers while respecting communicative properties of behavior.

Evening cortisol is associated with intra-individual instability in daytime napping in nursing home residents with dementia: an allostatic load perspective

BACKGROUND

Circadian rhythm disruption, reflected in alterations in sleep-wake activity and daytime napping behavior, is consistently reported in nursing home (NH) residents with dementia. This disruption may be reflected in day-to-day instability. The concept of allostatic load (AL), a measure of cumulative biological burden over a lifetime, may be a helpful model for understanding cortisol diurnal rhythm and daytime napping activity in this population. The purpose of this study was to examine the association between intra-individual daytime napping episodes and basal cortisol diurnal rhythm in NH residents with dementia in the context of AL.

METHOD

U sing a within-individual longitudinal design (N = 51), the authors observed and recorded daytime napping activity every 20 min for 10 hr per day across 4 consecutive days. The authors obtained saliva samples 4 times each day (upon participants' waking and within 1 hr, 6 hr, and 12 hr of participants' wake time) for cortisol analysis.

RESULTS

The authors categorized participants as high changers (HCs; day-to-day instability in napping activity) or low changers (LCs; day-to-day stability). There were no significant differences in resident characteristics between groups. There was a significant difference between HCs and LCs in napping episodes (F = 4.86, p = .03), with an interaction effect of evening cortisol on napping episodes in the HC group (F = 10.161, p = .001).

CONCLUSIONS

NH residents with unstable day-to-day napping episodes are more responsive to alterations in evening cortisol, an index of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. They may also be more amenable to environmental intervention, an avenue for further research.

To nap or not to nap: excessive daytime napping is associated with elevated evening cortisol in nursing home residents with dementia

BACKGROUND

Alterations in the sleep-wake cycle, including daytime napping, are consistently reported in persons with dementia (PWD). A dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis, indexed by elevated evening cortisol, may offer one explanation for these alterations. Alternatively, excessive daytime sleeping may alter cortisol rhythm and increase intraindividual variability, potentially contributing to increased environmental reactivity and behavioral symptoms. The purpose of this substudy (N = 12) was to examine the association between daytime napping and basal cortisol diurnal rhythm in nursing home residents with dementia.

METHOD

In this within-individual longitudinal design, saliva samples were obtained daily for 5 consecutive days upon waking and 30-45 min, 6 hr, and 12 hr after waking to obtain a cortisol diurnal rhythm. Behavior and sleep-wake state (nap/no nap) were observed and recorded every 20 min for 12 hr per day for 5 days.

RESULTS

Participants were categorized as high nappers (HNs) or low nappers (LNs). There was a significant difference in evening cortisol levels (t = -2.38, p = .032) and continence (t = 3.37, p = .007) between groups, with HNs exhibiting higher evening cortisol levels. There were no other significant differences in resident characteristics between the two groups.

CONCLUSIONS

These data suggest a link between excessive daytime napping and elevated evening cortisol in PWD consistent with findings in children. Elevated evening cortisol is an indication of a dysregulation in the HPA axis. These preliminary data support a close association between the sleep-wake cycle and HPA-axis regulation in PWD.

Validité et fidélité de l'Inventaire d'agitation de Cohen-Mansfield

Agitation in older persons is a major problem for the agitated individual and those around him/her. French-language measures of agitation with demonstrated validity and reliability are necessary for research and interventions in the French-speaking community. The goal of this study is to verify the reliability and validity of the “Inventaire d'agitation de Cohen-Mansfield” (IACM), a French version of the Cohen-Mansfield Agitation Inventory. The IACM measures the frequency of 29 agitated behaviours during a two-week period. Ninety-nine residents of a long-term care facility participated in this study. Results demonstrate the inter-rater reliability (r = .72), test-retest reliability (r = .72), internal consistency (Cronbach's alpha from .75 to .77), concurrent validity (r = .74) and construct validity (all r are significant, p < .05) of the IACM.

Morning Cortisol in Relation to Behavioral Symptoms of Nursing Home Residents With Dementia

Behavioral symptoms of dementia (BSD) are a significant challenge for elders, their caregivers, and clinicians, with a prevalence ranging between 66% and 98%. Although several studies have examined BSD type and frequency, few studies have examined a possible neuroendocrine basis of BSD. The purpose of this study was to examine the association between morning cortisol levels and BSD in nursing home (NH) residents. Method: Using a within-subject longitudinal design, saliva was collected four times daily for 5 days to obtain basal cortisol levels from 30 NH residents, aged 80 to 102. Behavior was observed every 20 min for 12 hr/day for 5 days. Mixed-model analysis was used to test the association between morning cortisol (MC) and BSD. To examine the association between MC and BSD across time, participants were divided into low (LM) and high morning (HM) cortisol groups. Results: A significant inverse association between mean overall BSD and morning cortisol (F = 12.71, p = .000) was found. A significant inverse association between low and high morning cortisol and behavior variability across time (F = 15.36. p = .000) was found. The LM group exhibited significantly more behavioral variability across the day than the HM cortisol group. There was a significant group difference between two co-occurring behaviors, vocalization, and restlessness (F = 19.59, p = .000). Conclusion: Although preliminary, these results suggest an association between morning cortisol and BSD. Low morning cortisol, potentially indicating HPA axis dysregulation, may increase vulnerability to BSD.

Comprehensive assessment of depression and behavioral problems in long-term care

BACKGROUND

The IPA Taskforce on Mental Health Issues in Long-Term Care Homes seeks to improve mental health care in long-term care (LTC) homes. The aim of this paper is to provide recommendations on comprehensive assessment of depression and behavioral problems in order to further stimulate countries and professionals to enhance their quality of care.

METHODS

Existing guidelines on comprehensive assessment of depression or behavioral problems in nursing home (NH) patients or patients residing in LTC homes were collected and a literature review was carried out to search for recent evidence.

RESULTS

Five guidelines from several countries all over the world and two additional papers were included in this paper as a starting point for the recommendations. Comprehensive assessment of depression in LTC homes consists of a two-step screening procedure: an investigation to identify factors that influence the symptoms, followed by a formal diagnosis of depression according to DSM-IV-TR or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease in cases of dementia. Comprehensive assessment of behavioral problems encompasses three steps: description and clarification of the behavior, additional investigation, and assessment of probable causes of the behavior. The procedure starts in the case of moderate behavioral problems.

CONCLUSION

The recommendations given in this paper provide a useful guide to professional workers in the LTC sector, but clinical judgment and the consideration of the unique aspects of individual residents and their situations is necessary for an optimal assessment of depression and behavioral problems. The recommendations should not be rigidly applied and implementation will differ from country to country.

Longitudinal analysis of differential effects on agitation of a therapeutic wander garden for dementia patients based on ambulation ability

A growth model within the framework of hierarchical linear modeling was used to assess the impact of visiting a wander garden on monthly agitation levels of a group of elderly veterans diagnosed with dementia, with attention to their ambulatory ability. A sample of 34 veterans residing in a locked ward in a dementia unit was observed for a baseline period and for twelve months after a wander garden was opened in their facility. Findings suggest that visiting the wander garden helped lower agitation levels in the dementia patients and that there was a differential effect based on the patient’s ability to walk unassisted.

Apolipoprotein epsilon4 status is associated with behavioral symptoms in nursing home residents with dementia

BACKGROUND

While the relationship of apolipoprotein E (APOE) to behavioral symptoms of dementia (BSD) has been studied in community-dwelling persons with AD, it has received limited attention within the nursing home (NH) population. The aim of this study was to examine the association between APOE genotype and BSD in NH residents using direct observation.

METHODS

Thirty-six participants, aged 71-102 years, were compared using a non-randomized two-group design with continuous measures. APOE genotype was obtained by buccal swab. BSD, including restlessness, escape restraint, tapping and banging, searching and wandering, pacing and walking, and vocalization, were measured using the Modified Agitated Behavior Rating Scale. Participants were observed every 20 minutes for 12 hours per day for five days. Each participant's mean behavior scores were compared according to the presence or absence of the APOE epsilon4 allele.

RESULTS

Resident characteristics included a mean MMSE of 10.44 indicating moderate to severe dementia and a mean of 3.44 medical co-morbidities. Fifty-six percent of the participants had one epsilon4 allele. A significant difference was found between APOE epsilon4+/4- and mean behavioral scores (F(1,31)) = 4.40, p = 0.04). Restlessness was significantly inversely correlated with MMSE (r = -0.367, p = 0.03), but not APOE genotype. There was no significant correlation between proxy reporting and direct observation (r = 0.257, p = 0.13).

CONCLUSION

Findings indicate that the presence of the APOE epsilon4+ genotype increases the risk for BSD in NH residents with dementia. Direct observation proved a more accurate estimate of BSD than proxy report.

Anticonvulsants in the treatment of aggression in the demented elderly: an update

INTRODUCTION

Complex psychopathological and behavioral symptoms, such as delusions and aggression against care providers, are often the primary cause of acute hospital admissions of elderly patients to emergency units and psychiatric departments. This issue resembles an interdisciplinary clinically highly relevant diagnostic and therapeutic challenge across many medical subjects and general practice. At least 50% of the dramatically growing number of patients with dementia exerts aggressive and agitated symptoms during the course of clinical progression, particularly at moderate clinical severity.

METHODS

Commonly used rating scales for agitation and aggression are reviewed and discussed. Furthermore, we focus in this article on benefits and limitations of all available data of anticonvulsants published in this specific indication, such as valproate, carbamazepine, oxcarbazepine, lamotrigine, gabapentin and topiramate.

RESULTS

To date, most positive and robust data are available for carbamazepine, however, pharmacokinetic interactions with secondary enzyme induction limit its use. Controlled data of valproate do not seem to support the use in this population. For oxcarbazepine only one controlled but negative trial is available. Positive small series and case reports have been reported for lamotrigine, gabapentin and topiramate.

CONCLUSION

So far, data of anticonvulsants in demented patients with behavioral disturbances are not convincing. Controlled clinical trials using specific, valid and psychometrically sound instruments of newer anticonvulsants with a better tolerability profile are mandatory to verify whether they can contribute as treatment option in this indication.

Clozapine for treatment-resistant agitation in dementia

Few studies have examined the potential role of clozapine in treatment of agitation in dementia patients who have previously failed to respond to standard pharmacotherapy. We conducted a systematic chart review of all elderly patients admitted to our inpatient unit between 2001 and 2004. Of them, 16 dementia patients were treated with clozapine for treatment-resistant agitation, and their charts were blindly rated by 3 clinicians on the Clinical Global Impression (CGI) Scale, Brief Agitation Rating Scale (BARS), and the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF). Overall, clozapine therapy seemed beneficial in treatment-resistant agitation in dementia patients.

Structured assessment of mental health status in psychogeriatrics: validity of the French HoNOS65+

OBJECTIVE

To assess the reliability, validity, and feasibility of a French version of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+).

METHOD

Twenty mental health professionals completed the scale for 126 elderly patients. We assessed interrater reliability in inpatient and outpatient settings, together with construct and discriminant validity, as well as concurrent validity compared with several widely used clinical instruments.

RESULTS

Excellent agreement among raters was observed in the outpatient subgroup (kappa range 0.77 to 1.00), whereas interrater reliability was modest in the inpatient subgroup (kappa values < 0.55). In cases where the patient-caregiver relationship lasted more than 1 month, the reliability of the scale improved. Construct validity analysis revealed no subscale structure. All items except "self-injury" displayed high concurrent validity (significant Spearman correlations with 8 other questionnaires). In terms of discriminant validity, the "cognitive impairment" (area under the curve [AUC] 0.91) and "depressive symptoms" (AUC 0.79) items showed high sensitivity and specificity values.

CONCLUSION

Our results indicate that the French version of HoNOS65+ is a promising clinical assessment tool to evaluate mental disorders in the elderly in outpatient settings. We support its use in routine clinical practice, with the condition that a relatively long and individualized patient-caregiver relationship has been established.

The quality of care in Norwegian nursing homes

BACKGROUND

Promoting the quality of life is an importing aim of the long-term care for the elderly, and the quality of life is related to quality of care (QoC). This way the QoC in nursing homes, and its correlates, is an interesting subject.

AIM

To describe to what degree Norwegian nursing homes provide services in line with the core areas of the 'regulation of care' and whether patient or ward characteristics are associated with the QoC.

METHODS AND MATERIAL

Cross-sectional study where data were collected in structured interview of the nursing staff in 251 wards regarding 1926 patients.

RESULTS

Most of the patients receive good basic care in Norwegian nursing homes, but taking part in leisure activities and having the opportunity to go out for a walk are more often neglected. Acceptable QoC had a strongly negative association with patient characteristics such as low function in mental capacity, low function in activities of daily living and aggressive behaviour. In most of the measured areas of QoC, ward characteristics, such as type of ward, size of ward and staffing ratio, do have an influence on QoC.

The effect of staff training on the use of restraint in dementia: a single-blind randomised controlled trial

BACKGROUND

Use of restraint amongst institutionalised elderly with dementia and problem behaviour not only remains widespread, but also appears to be accepted as inevitable.

OBJECTIVE

The aim of this study was to reduce problem behaviour and the use of restraint in demented patients using a staff training program as intervention.

METHODS

The study was a randomised single-blind controlled trial and took place in Stavanger, Norway. Four nursing homes were randomised to a control or an intervention group after stratification for size. The intervention consisted of a full day seminar, followed by a one-hour session of guidance per month over six months. The content of the educational program focused on the decision making process in the use of restraint and alternatives to restraint consistent with professional practice and quality care. The primary outcome measures were number of restraints per patient in the nursing homes in one week and agitation as measured with the Brief Agitation Rating Scale (BARS). These were rated before and immediately after the intervention was completed. The assessments were performed blind to design and randomisation group.

RESULTS

Clinical and demographic variables did not differ between the intervention and control groups at baseline. After the intervention period, the number of restraints had declined by 54% in the treatment group, and increased by 18% in the control group. The difference between the two groups was statistically significant ( p = 0.013). There was a trend towards higher BARS score in the intervention compared to the control group at follow up ( p = 0.052).

CONCLUSION

Although the level of agitated behaviour remained unchanged or increased slightly, the educational program led to a significant reduction of the use of restraint in institutionalised elderly with dementia. These results suggest that educational programs can improve the quality of care of people with dementia.

Concealment of drugs in food and beverages in nursing homes: cross sectional study

OBJECTIVE

To examine the practice of concealing drugs in patients' foodstuff in nursing homes.

DESIGN

Cross sectional study with data collected by structured interview.

SETTING

All five health regions in Norway.

PARTICIPANTS

Professional carers of 1362 patients in 160 regular nursing home units and 564 patients in 90 special care units for people with dementia.

MAIN OUTCOME MEASURES

Frequency of concealment of drugs; who decided to conceal the drugs; how this practice was documented in the patients' records; and what types of drugs were given this way.

RESULTS

11% of the patients in regular nursing home units and 17% of the patients in special care units for people with dementia received drugs mixed in their food or beverages at least once during seven days. In 95% of cases, drugs were routinely mixed in the food or beverages. The practice was documented in patients' records in 40% (96/241) of cases. The covert administration of drugs was more often documented when the physician took the decision to hide the drugs in the patient's foodstuff (57%; 27/47) than when the person who made the decision was unknown or not recorded (23%; 7/30). Patients who got drugs covertly more often received antiepileptics, antipsychotics, and anxiolytics compared with patients who were given their drugs openly.

CONCLUSIONS

The covert administration of drugs is common in Norwegian nursing homes. Routines for such practice are arbitrary, and the practice is poorly documented in the patients' records.

Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management

OBJECTIVES

To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.

DESIGN

Cross-sectional study.

SETTINGS

A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina).

PARTICIPANTS

A total of 2,078 RC/AL residents aged 65 and older.

MEASUREMENT

Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined.

RESULTS

Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness).

CONCLUSION

Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting.

Prevention of weight loss in dementia with comprehensive nutritional treatment

OBJECTIVES

To determine whether body weight can be maintained or improved in dementia residents of special care units (SCUs) using a comprehensive intervention strategy.

DESIGN

Quasi-experimental with an interventional site and a noninterventional site.

SETTING

Four SCUs in two long-term care facilities in Ontario.

PARTICIPANTS

The intervention site included 33 residents; the comparison site included 49 residents.

MEASUREMENTS

Weight change over time was the primary outcome. Three time periods were compared: 9-month baseline period, 9-month intervention period (enhanced dietitian monitoring and menu changes at intervention site), and 12-month postintervention period (only menu changes at intervention site). Comparisons were made within and between sites. Full nutritional assessments were completed for the intervention group. Medical charts and basic anthropometric, behavioral, and cognitive measures were completed in both groups to determine baseline site differences. Weight change over time was analyzed with a repeated measures analysis, controlling for various covariates. Bivariate analyses were completed for other outcomes of death, number of infections, falls, and hospital days.

RESULTS

The intervention period that included the dietitian time and menu changes significantly promoted weight gain, compared with the standard treatment at the comparison facility. Other covariates of pacing, type of dementia, sex, age, number of comorbid conditions, and medications were also significant predictors of weight change. Weight gain or maintenance regardless of site was associated with survival.

CONCLUSION

Body weight can be maintained in residents of SCUs regardless of pacing and other clinical characteristics. The comprehensive intervention of clinical dietitian time and an enhanced menu designed to be individualized for ambulatory people with dementia promoted significant gains in body weight. A minimum 5% weight gain is associated with survival in these residents of SCUs.