[Differential efficacy of two psychoeducational interventions for dementia family caregivers]. Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. Project CARE: a randomized controlled trial of a behavioral intervention group for Alzheimer's disease caregivers. Effects of the home environmental skill-building program on the caregiver-care recipient dyad: 6-month outcomes from the Philadelphia REACH Initiative. Can training community mental health nurses to support family carers reduce behavioural problems in dementia? An exploratory pragmatic randomised controlled trial. A randomized controlled trial of a behavior advisory service for hospitalized older patients with confusion. Interventions with care givers of dementia patients: comparison of two approaches. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. Behavioural management in nursing and residential homes: a randomised controlled trial. Behavioural management of aggression in dementia: a randomized controlled trial. Impact of two psychosocial interventions on white and African American family caregivers of individuals with dementia. Treatment of agitation in AD: a randomized, placebo-controlled clinical trial. No long-term effect of behavioral treatment on psychotropic drug use for agitation in Alzheimer's disease patients. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. STAR: a dementia-specific training program for staff in assisted living residences. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. Training community consultants to help family members improve dementia care: a randomized controlled trial.
The aim of this work is to compare the effectiveness of two psychoeducational interventions for dementia caregivers: a cognitive behavioral one (PCC), aimed at the modification of dysfunctional thoughts about caregiving, and another one consisting in problem solving skills training (PSP) for caregivers, with the aim of modifying the behavioral problems of their relative.
                Seventy five caregivers were asked to participate in an intervention program, of whom 31 finally completed the study. Both group interventions are compared with a control group (CG). The caregiver groups were randomly assigned to each experimental condition. Pre, post intervention, and follow up assessments of the following variables have been made: depression, perceived stress, frequency of behavioral problems, perceived stress associated with the behavioral problems and dysfunctional thoughts about caregiving.
                Following the intervention, caregivers in the PCC program show significantly less perceived stress than the other two groups. In the same direction, a trend exists to a significant reduction of the stress associated with the behavioral problems. In the follow up assessment, caregivers of the PCC program significantly report less relative's behavioral problems than the other two groups. Caregivers of the PCC program have less dysfunctional thoughts than the other two groups, differences almost reaching significance.
                Benefits of a psychoeducational intervention vary as a function of the contents it includes. The importance of intervening on the caregiver dysfunctional thoughts for an adequate coping with caregiving is highlighted. Exercise training for patients with Alzheimer disease combined with teaching caregivers how to manage behavioral problems may help decrease the frailty and behavioral impairment that are often prevalent in patients with Alzheimer disease.
                To determine whether a home-based exercise program combined with caregiver training in behavioral management techniques would reduce functional dependence and delay institutionalization among patients with Alzheimer disease.
                Randomized controlled trial of 153 community-dwelling patients meeting National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer Disease and Related Disorders Association criteria for Alzheimer disease, conducted between June 1994 and April 1999.
                Patient-caregiver dyads were randomly assigned to the combined exercise and caregiver training program, Reducing Disability in Alzheimer Disease (RDAD), or to routine medical care (RMC). The RDAD program was conducted in the patients' home over 3 months.
                Physical health and function (36-item Short-Form Health Survey's [SF-36] physical functioning and physical role functioning subscales and Sickness Impact Profile's Mobility subscale), and affective status (Hamilton Depression Rating Scale and Cornell Depression Scale for Depression in Dementia).
                At 3 months, in comparison with the routine care patients, more patients in the RDAD group exercised at least 60 min/wk (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.25-6.39; P =.01) and had fewer days of restricted activity (OR, 3.10; 95% CI, 1.08-8.95; P<.001). Patients in the RDAD group also had improved scores for physical role functioning compared with worse scores for patients in the RMC group (mean difference, 19.29; 95% CI, 8.75-29.83; P<.001). Patients in the RDAD group had improved Cornell Depression Scale for Depression in Dementia scores while the patients in the RMC group had worse scores (mean difference, -1.03; 95% CI, -0.17 to -1.91; P =.02). At 2 years, the RDAD patients continued to have better physical role functioning scores than the RMC patients (mean difference, 10.89; 95% CI, 3.62-18.16; P =.003) and showed a trend (19% vs 50%) for less institutionalization due to behavioral disturbance. For patients with higher depression scores at baseline, those in the RDAD group improved significantly more at 3 months on the Hamilton Depression Rating Scale (mean difference, 2.21; 95% CI, 0.22-4.20; P =.04) and maintained that improvement at 24 months (mean difference, 2.14; 95% CI, 0.14-4.17; P =.04).
                Exercise training combined with teaching caregivers behavioral management techniques improved physical health and depression in patients with Alzheimer disease. The neuropsychiatric symptoms associated with Alzheimer's disease are a major contributor to caregiver distress and burden. Despite recent efforts to teach caregivers skills to manage neuropsychiatric symptoms and reduce burden, there continues to be limited evidence that these strategies have helped caregivers of individuals with Alzheimer's disease to effectively manage neuropsychiatric symptoms. We report here on Project CARE, a randomized controlled trial designed to test the effectiveness of a caregiver-based multicomponent behavioral intervention aimed to reduce caregiver distress related to neuropsychiatric symptoms, as well as general caregiver burden, and to decrease neuropsychiatric symptom severity among individuals with Alzheimer's disease.
                The behavioral intervention involved five weekly sessions designed to teach caregivers specific techniques for managing patient neuropsychiatric symptoms in the home environment. Through the use of a randomized control trial, 80 caregivers were assigned to either the behavioral intervention group or a psychoeducational control group and were assessed both before and after the intervention.
                Compared with caregivers in the control group, caregivers in the behavioral intervention group displayed significantly greater reductions in caregiver distress related to neuropsychiatric symptoms (p=.005). Global caregiver burden, however, did not decrease significantly for caregivers in either group (p>.05). Although it was not statistically significant, there was a trend toward greater reductions in care recipients' neuropsychiatric symptom severity in the intervention group (p=.10).
                The current findings suggest that targeted, group-based behavioral interventions are effective for reducing distress related to neuropsychiatric symptoms among caregivers of individuals with Alzheimer's disease and for reducing care recipients' neuropsychiatric symptoms. We examine 6-month effects of the Environmental Skill-Building Program on caregiver well-being and care recipient functioning and whether effects vary by caregiver gender, race (White or non-White), and relationship (spouse or nonspouse).
                We enrolled 255 family caregivers of community-residing persons with Alzheimer's disease or related disorders, of whom 190 participated in a follow-up interview. Caregivers were randomized to a usual care control group or intervention group that received five home contacts and one telephone contact by occupational therapists, who provided education, problem-solving training, and adaptive equipment. Baseline and 6-month follow-up included self-report measures of caregiver objective and subjective burden, caregiver well-being, and care recipient problem behaviors and physical function.
                Compared with controls (n = 101), intervention caregivers (n = 89) reported less upset with memory-related behaviors, less need for assistance from others, and better affect. Intervention spouses reported less upset with disruptive behaviors; men reported spending less time in daily oversight; and women reported less need for help from others, better affect, and enhanced management ability, overall well-being, and mastery relative to control group counterparts. Statistically significant treatment differences were not found for hours helping with instrumental activities of daily living, upset with providing assistance with instrumental activities of daily living and activities of daily living, perceived change in somatic symptoms, White versus non-White caregivers, or care recipient outcomes.
                The Environmental Skill-Building Program reduces burden and enhances caregiver well-being in select domains and has added benefit for women and spouses. Community mental health nurses (CMHNs) are the backbone of specialist mental health services in the UK. This study evaluated the effects of training CMHNs in a systematic psychosocial intervention (PSI), to help family carers manage behavioural changes in their relative with dementia.
                One hundred and thirteen family carers received PSI support from a 'trained' (experimental), or a 'usual practice' (control) CMHN. Primary (day-to-day behaviour problems and management) and secondary (carer mood) outcome measures were obtained at baseline, 6, 12 and 18 months. CMHN training and supervision commenced prior to, and continued throughout, the 18-month study.
                Patient cognition declined in both groups, but problem behaviour reduced in experimental group families. However this effect was associated with the practice of some, not all, CMHNs. Carer management and mood improved with PSI support. In contrast, by 18 months, families supported by conventional CMHNs reported reduced coping resources, increased problem behaviour and their level of depression worsened. Only two CMHNs adhered to the PSI-protocol.
                Some, but not all, 'trained' CMHNs used the PSI to help family carers reduce behavioural problems. A relatively long but not intensive PSI of 12-18 months was needed to moderate carer mood. Dementia-specific practice arrangements, training and sustained clinical supervision are important for the delivery of effective psychosocial interventions in dementia.
                Copyright (c) 2007 John Wiley & Sons, Ltd. To determine whether individualized advice on non-pharmacological strategies for hospitalized older patients with confusion and behavioral problems can improve levels of agitation and reduce the use of psychotropic medication.
                Pragmatic randomized controlled trial in two metropolitan teaching hospitals in South Australia. Seventy-one older patients with confusion and a behavioral disturbance were randomly allocated to receive either an assessment and ongoing individualized advice from an extended practice nurse on non-pharmacological strategies or usual care. Usual care included an assessment by a geriatrician.
                Primary outcomes were levels of agitation (Pittsburgh Agitation Scale), appropriateness of psychotropic medication prescribing (Medication Appropriateness Index) and levels of psychotropics administered (chlorpromazine and diazepam dose equivalents). Secondary outcomes were length of stay, discharge destination, number of falls, restraint use and satisfaction from nursing staff and next of kin.
                Levels of agitation were modest at baseline with mean PAS intervention group 3.4 (SD = 0.5) and control group 4.0 (SD = 0.4) and both groups improved over time to 1.7 (SD = 0.4) for the intervention group and 1.8 (SD = 0.3) for the control group on the final day of data collection. Median length of follow-up was nine days. There was no effect of the intervention on levels of agitation, amount and appropriateness of psychotropic medication prescribed and administered, falls, length of stay, discharge destination, restraint use and nursing and next of kin satisfaction.
                A nursing consultation service providing individualized non-pharmacological advice does not improve patient agitation or use of psychotropic medication for older patients with confusion and behavioral problems in an acute hospital. We compared the effect of two approaches, family counseling and support groups, for relieving the stress and burden experienced by care givers of dementia patients. Both treatments are designed to implement features of a stress-management model that have been identified in prior research with this population: providing information about the patient's disease and its effects on behavior, teaching behavioral problem solving for managing difficult behavior, and identifying potential support for care givers. Subjects were primary care givers of dementia patients living in the community; they included husbands, wives, daughters, and other relatives. Although subjects in the treatment groups made significant gains over time, they did not differ from wait-list subjects who showed similar improvements. One-year follow-up interviews indicated that gains made during the treatment period were maintained. To test the effects of an intervention that helps families manage distressing behaviors in family members with dementia.
                Two-group randomized trial.
                In home.
                Two hundred seventy-two caregivers and people with dementia.
                Up to 11 home and telephone contacts over 16 weeks by health professionals who identified potential triggers of patient behaviors, including communication and environmental factors and patient undiagnosed medical conditions (by obtaining blood and urine samples) and trained caregivers in strategies to modify triggers and reduce their upset. Between 16 and 24 weeks, three telephone contacts reinforced strategy use.
                Primary outcomes were frequency of targeted problem behavior and caregiver upset with and confidence managing it at 16 weeks. Secondary outcomes were caregiver well-being and management skills at 16 and 24 weeks and caregiver perceived benefits. Prevalence of medical conditions for intervention patients were also examined.
                At 16 weeks, 67.5% of intervention caregivers reported improvement in targeted problem behavior, compared with 45.8% of caregivers in a no-treatment control group (P=.002), and reduced upset with (P=.03) and enhanced confidence managing (P=.01) the behavior. Additionally, intervention caregivers reported less upset with all problem behaviors (P=.001), less negative communication (P=.02), less burden (P=.05), and better well-being (P=.001) than controls. Fewer intervention caregivers had depressive symptoms (53.0%) than control group caregivers (67.8%, P=.02). Similar caregiver outcomes occurred at 24 weeks. Intervention caregivers perceived more study benefits (P<.05), including ability to keep family members home, than controls. Blood and urine samples of intervention patients with dementia showed that 40 (34.1%) had undiagnosed illnesses requiring physician follow-up.
                Targeting behaviors upsetting to caregivers and modifying potential triggers improves symptomatology in people with dementia and caregiver well-being and skills.
                © 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society. As more and more elderly people are being cared for in residential and nursing homes, how best can their psychiatric needs be met? We report on evaluation of a behavioural intervention by an old-age psychiatry hospital outreach team.
                This randomised controlled trial of a training and education intervention over 6 months was done in south Manchester, UK. 12 matched nursing and residential homes were randomised to the control or intervention group and within each, the staff selected 10 residents whose behavioural problems made them difficult to care for. Care staff in the intervention homes attended seminars from the hospital outreach team and received weekly visits from a psychiatric nurse to assist in developing care planning skills. The main outcome measures were cognitive impairment and depression, behavioural disturbance, and functional ability, assessed by the geriatric mental state schedule, Crichton Royal behaviour rating scale, and Barthel index, respectively.
                Residents in the intervention group had significantly improved scores for depression (before-and-after change difference -0.5 [95% CI -0.8 to -0.1]) and for cognitive impairment (-0.7 [-1.1 to -0.2]) but not for behaviour rating or Barthel index.
                Elderly residents can benefit from improved quality of care achieved by training from a hospital outreach team. To evaluate the efficacy of a brief behaviour management training programme for family carers of patients with dementia and aggressive behaviour.
                A randomized controlled trial of a four-session, community-based behaviour management programme. The primary outcome measure was the Rating Scale for Aggressive Behaviour in the Elderly.
                62 patients with dementia, and their co-resident carers.
                There were no significant differences in aggression scores between behaviour management and control groups at follow-up. After adjusting for baseline differences in Rating Scale for Aggressive Behaviour in the Elderly scores, there was a trend towards a reduction in aggressive behaviour in the patients in the behaviour management group compared with those in the control group (F = 3.37, P = 0.071).
                This study adds to the small evidence base for the effectiveness of behavioural management strategies in dementia. We developed manual-guided, replicable interventions based on common needs and cultural preferences of White and African American family caregivers (CGs) of individuals with dementia, and we evaluated these interventions after a 6-month follow-up.
                We randomly assigned White (n = 70) and African American (n = 48) CGs of individuals with dementia to either a skills training condition or a minimal support control condition.
                The degree of treatment implementation was methodically assessed, and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs. CGs in both groups reported decreasing levels of problem behaviors and appraisals of behavioral bother, and increased satisfaction with leisure activities over time. On a measure of appraisal of distress related to behavior problems, White CGs showed more improvement in the minimal support control condition, and African American CGs showed the greatest improvements in the skills training condition. Spouse and nonspouse CGs also showed differential responses to intervention.
                Brief manual-guided interventions can be effective with White and African American CGs, and greater attention should be paid to possible differential responses to interventions by race and relationship to care recipient. Treatment of agitation is a crucial problem in the care of patients with AD. Although antipsychotic and antidepressant medications and behavior management techniques (BMT) have each been used to treat agitation, clinical trials of these treatments have been characterized by small sample sizes and uncontrolled treatment designs.
                To compare haloperidol, trazodone, and BMT with placebo in the treatment of agitation in AD outpatients.
                A total of 149 patients with AD and their caregivers participated in a randomized, placebo-controlled, multicenter trial. Blind assessment was conducted at baseline and after 16 weeks of treatment. The three active treatments were haloperidol, trazodone, and BMT. The Alzheimer's Disease Cooperative Study Clinical Global Impression of Change was the primary outcome measure. Secondary outcomes included patient agitation, cognition, and function, and caregiver burden.
                Thirty-four percent of subjects improved relative to baseline. No significant differences on outcome were obtained between haloperidol (mean dose, 1.8 mg/d), trazodone (mean dose, 200 mg/d), BMT, or placebo. Significantly fewer adverse events of bradykinesia and parkinsonian gait were evident in the BMT arm. No other significant difference in adverse events was seen. Symptoms did not respond differentially to the different treatments.
                Comparable modest reductions in agitation occurred in patients receiving haloperidol, trazodone, BMT, and placebo. More effective pharmacologic, nonpharmacologic, and combination treatments are needed. Th determine if teaching caregivers behavior management techniques (BMTs) reduces long-term psychotropic use in Alzheimer's disease (AD) patients, we examined 12-month follow-up data from a 4-month randomized study comparing placebo, BMTs, trazodone, and haloperidol for the treatment of agitated behaviors in persons with AD. After 4 months, treatment was allowed with any agent. Between 42.8% and 51% of AD patients received additional psychotropics between 4 and 12 months. The relative risk of being prescribed any psychotropic drug after the 4-month trial was at or about 1.0 for subjects in each drug arm or placebo arm versus BMTs. We concluded that teaching caregivers BMTs did not diminish long-term prescription of psychotropic drugs. Evidence for improved outcomes for people with dementia through provision of person-centred care and dementia-care mapping is largely observational. We aimed to do a large, randomised comparison of person-centred care, dementia-care mapping, and usual care.
                In a cluster randomised controlled trial, urban residential sites were randomly assigned to person-centred care, dementia-care mapping, or usual care. Carers received training and support in either intervention or continued usual care. Treatment allocation was masked to assessors. The primary outcome was agitation measured with the Cohen-Mansfield agitation inventory (CMAI). Secondary outcomes included psychiatric symptoms including hallucinations, neuropsychological status, quality of life, falls, and cost of treatment. Outcome measures were assessed before and directly after 4 months of intervention, and at 4 months of follow-up. Hierarchical linear models were used to test treatment and time effects. Analysis was by intention to treat. This trial is registered with the Australia and New Zealand Clinical Trials Registry, number ACTRN12608000084381.
                15 care sites with 289 residents were randomly assigned. Pairwise contrasts revealed that at follow-up, and relative to usual care, CMAI score was lower in sites providing mapping (mean difference 10.9, 95% CI 0.7-21.1; p=0.04) and person-centred care (13.6, 3.3-23.9; p=0.01). Compared with usual care, fewer falls were recorded in sites that used mapping (0.24, 0.08-0.40; p=0.02) but there were more falls with person-centred care (0.15, 0.02-0.28; p=0.03). There were no other significant effects.
                Person-centred care and dementia-care mapping both seem to reduce agitation in people with dementia in residential care. This article describes, and provides data on, an innovative, comprehensive, dementia-specific training program designed to teach direct care staff in assisted living residences to improve care and reduce problems in residents with dementia.
                STAR-which stands for Staff Training in Assisted living Residences-provides two 4-hr workshops augmented by four individualized on-site consultations and three leadership sessions. Developed by means of an iterative process of implementation and revision, it was then evaluated in a small randomized controlled trial. A total of 114 staff and 120 residents in 15 residences participated.
                STAR was exceptionally well received. Training details are provided with a discussion of unique challenges inherent in implementation. Following training, STAR residents evidenced significantly reduced levels of affective and behavioral distress compared with control residents. Furthermore, STAR residents improved whereas control residents worsened (p < .05). Staff with STAR staff training reported less adverse impact and reaction to residents' problems (p < .05) and more job satisfaction (p < .10) compared with control staff.
                STAR is an effective training program for direct care staff working with dementia residents in assisted living. The importance of continued development and investigation of STAR efficacy and effectiveness is underscored by the growing numbers of residents with dementia who are receiving care in these settings. 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.
                Cluster randomised controlled trial with blinded assessment of outcome.
                12 specialist nursing homes for people with dementia in London, Newcastle, and Oxford.
                Residents of the 12 nursing homes; numbers varied during the study period.
                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.
                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.
                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.
                Promotion of person centred care and good practice in the management of patients with dementia with behavioural symptoms provides an effective alternative to neuroleptics. We investigated whether community consultants could be trained to teach family caregivers a systematic behavioral approach for reducing mood and behavior problems in persons with Alzheimer's disease.
                This study consisted of a randomized controlled trial; we randomly assigned 95 family caregivers and care recipients with Alzheimer's disease to STAR-caregivers (STAR-C) or control groups. Masked interviewers conducted assessments at baseline, after treatment, and after 6 months. Consultants were master's-level health care professionals who were currently practicing in community settings serving older adults. We assessed the extent to which consultants were able to learn and adhere to the treatment protocol, and the relationship between adherence and measures of caregiver mood, burden, and care recipient mood and behavior.
                Community consultants were able to learn and adhere to the behavioral treatment protocol. Caregivers receiving STAR-C training showed significant improvements in depression, burden, and reactivity to behavior problems in the care recipient. There were also significant reductions in the frequency and severity of care recipient behavior problems, and improved quality of life. Results were maintained at 6-month follow-up.
                Community-based consultants successfully implemented a behavioral intervention with family caregivers of persons with Alzheimer's disease. Consequently, STAR-C seems to be a practicable and reasonable evidenced-based approach to caregiver training in actual clinical settings.
The delivery of FA has been incorporated within wide ranging multi-component programmes and study designs have varied according to setting - i.e. family care, care homes and hospital, with surprisingly few studies located in care homes. Our findings suggest potential beneficial effects of multi-component interventions, which utilise FA. Whilst functional analysis for challenging behaviour in dementia care shows promise, it is too early to draw conclusions about its efficacy.