Can the PROPER intervention reduce psychotropic drug prescription in nursing home residents with dementia? Results of a cluster-randomized controlled trial.

OBJECTIVES: To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms. DESIGN: A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months. SETTING: Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands. PARTICIPANTS: Three hundred eighty nursing home residents with dementia. INTERVENTION: The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation. MEASUREMENTS: Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms. RESULTS: The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6 months (p = 0.01). Effects for the individual drug groups were minor (differences of 1.6 percentage points and below per 6 months) and not statistically significant. The occurrence of neuropsychiatric symptoms remained stable in both the intervention and control groups during the follow-up of 18 months. CONCLUSIONS: The PROPER intervention failed to demonstrate effectiveness in reducing the prevalence of psychotropic drugs. It may be interesting to enrich the intervention with components that address personal attitudes and communication between nursing home professionals, not only with respect to the prescription of psychotropic drugs, but also to neuropsychiatric symptoms.The study has been registered in The Netherlands Trial Register (NTR3569).

[COVID-19 in nursing homes A study of diagnosis, symptomatology and disease course]. / Covid-19 in verpleeghuizen.

OBJECTIVE: To describe the diagnosis, symptomatology and disease course of COVID-19 in nursing home (NH) residents in the Netherlands. DESIGN: Prospective cohort study. METHOD: Data on NH residents with suspected COVID-19 were collected from the electronic patient records. Data were collected on diagnostic status (COVID-19: confirmed/excluded (using the RT-PCR test)), symptomatology (typical/atypical and other symptoms, body temperature and oxygen saturation) and, in the case of confirmed COVID-19, on disease course (recovered/clinically improved/deteriorated, deceased). We described and compared the symptomatology in NH residents with confirmed COVID-19 and NH residents in whom COVID-19 had been excluded. We also analysed mortality risk using survival analysis. We used registrations from the period 18 March to15 April 2020 for this study. RESULTS: We reported on 1,969 NH residents with suspected COVID-19. The diagnosis was confirmed in 857 patients (43.5%); diagnosis was excluded in 1,112 (56.5%) patients. Among patients with confirmed COVID-19, 65% had coughs, 70% had fever, 33% had shortness of breath, 28% had delirium/confusion and 10% had a sore throat; in patients in whom COVID-19 was excluded these symptoms were experienced in 70%, 47%, 45%, 26% and 13% of patients, respectively. Of the patients with confirmed COVID-19, 48% died within 30 days (95% CI: 36-44%), versus 20% of the patients in whom COVID-19 was excluded (95% CI: 11-15%). CONCLUSION: There is a lot of overlap in symptomatology between NH residents with COVID-19 and those with other acute diseases. An RT-PCR test is required to be able to make the distinction better. The mortality risk in patients with confirmed COVID-19 is significantly higher than in patients in whom covid-19 is excluded.

The Application of the Concept of Resilience in Aging Research and Older Adult Care: A Focus Group Study.

Introduction: Research incorporating resilience, a concept featuring a positive outcome despite some type of stressor, has the potential to identify possibilities for promotion of the well-being of older people. This study aims to gain insight into the value and potential applications of resilience in both research and care practice from the perspective of researchers and care professionals. Specifically, the value of two scientific approaches, the a priori (i.e., based on a priori definition of a stressor and outcome) and dynamical systems approaches (i.e., based on mathematically modeled patterns in the real-time response to perturbations), was explored. Methods: Focus groups were performed to explore the thoughts of academic researchers from different disciplines in the fields of aging and care and care professionals on the application of the concept of resilience, including the a priori and dynamical systems approaches. Analysis of these focus groups was based on the framework method. Results: Five focus groups were held with a total of nine researchers from different disciplines (e.g., epidemiology, sociology) and 15 older adult care professionals from different professions (e.g., elderly care physician, physiotherapist). The participants described resilience as a concept with value for both aging research and care through its positive connotation and comprehensiveness. Continued research was thought to play an important role in clearing up some of the existing ambiguity surrounding resilience. The importance of resilience in the context of both high- and low-intensity stressors was underscored. The a priori and dynamical systems approaches were considered to have their specific advantages and disadvantages on both conceptual and feasibility levels. Therefore, the use of both approaches, side by side and in combination, was suggested. Conclusion: This qualitative exploration among researchers and care professionals confirms that the concept of resilience, including the a priori and dynamical systems approaches, is valuable. However, more work is necessary before can be delivered on the potential of resilience in aging research and older adult care practice. Greater conceptual and operational clarity can be achieved through more qualitative studies on the concept that take the perspective of older people into account and through empirical studies that work with both approaches simultaneously and/or in combination.

Resilience in older persons: A systematic review of the conceptual literature.

Although ageing research increasingly incorporates resilience, a common notion on what resilience means is lacking. We aimed to give a comprehensive overview of the conceptual literature on resilience in older persons, identifying areas of consensus and variation/debate. A systematic search of eight databases from different disciplines led to the inclusion of 36 texts. Across the conceptual literature of resilience in older persons, three common features of descriptions of resilience were identified: a stressor, a response and a mechanism. Based on differences in their interpretation of how resilience is expressed we distinguished two perspectives. The first, classical and most widely applied perspective, describes the expression of resilience as a positive response to a high intensity stressor. The second, newer perspective, describes resilience in the context of responses relative to equilibrium, following low intensity stressors. Almost all descriptions across the two perspectives describe the resilience mechanism to be dynamic and emphasize the importance of the context in achieving resilience. This review provides clarity on the current conceptual status of resilience in older persons, an important step towards a higher level of consistency in the future use of resilience in ageing.

Effect of caffeine on sleep and behaviour in nursing home residents with dementia.

BACKGROUND AND GOAL: Sleep problems and challenging behavioural symptoms are frequently reported among nursing home residents with dementia. Coffee with caffeine is consumed frequently by these residents and can have a negative effect on sleep and behaviour in older persons with dementia. In this interventional study, the effect of caffeine reduction on sleep and challenging behavioural symptoms in nursing home residents with dementia was investigated. METHODS: In 21 nursing home residents with dementia living in 1 dementia special care unit, caffeine was gradually eliminated in the afternoon and evening. During pre-intervention and post-intervention period the care workers daily scored sleep by a specially developed sleep questionnaire. Behavioural symptoms were scored in the afternoon and evening using four items of the NPI-NH: agitation/aggression, apathy, irritability and aberrant motor behaviour. RESULTS: A significant improvement in sleep scores (Wilcoxon signed-rank test, p = 0.015) and apathy (Wilcoxon signed-rank test, p = 0.020) was found after eliminating caffeine intake in the afternoon and evening. No significant changes occurred in agitation/aggression, irritability and aberrant motor behaviour. DISCUSSION: This pre-post pilot study found a significant positive effect of caffeine reduction on sleep and apathy and warrants further investigation in a larger controlled study.

Efficacy of antipsychotics in dementia depended on the definition of patients and outcomes: a meta-epidemiological study.

OBJECTIVES: Postulating that efficacy of antipsychotics for agitation and psychosis in dementia is best estimated in trials among patients with these symptoms and with symptom-specific outcomes, we investigated whether clinically broader definitions affected the pooled efficacy. STUDY DESIGN AND SETTING: Trials were searched in multiple databases and categorized according to patient population (agitated, psychotic, and mixed) and outcome scale (agitation, psychosis, and generic). Standardized mean differences with 95% confidence intervals were calculated for conventional and atypical antipsychotics separately. RESULTS: Thirty trials met our inclusion criteria. Conventional antipsychotics might have a small effect in agitated patients on agitation scales (-0.44, -0.88, 0.01) and in psychotic patients on psychosis scales (-0.31, -0.61, -0.02). There was no effect on generic scales. Efficacy of atypical antipsychotics was not established in agitated patients on agitation scales (-0.15, -0.43, 0.13) and in psychotic patients on psychosis scales (-0.11, -0.20, -0.03) but was small in mixed patients on agitation scales (-0.29, -0.40, -0.18). CONCLUSION: Pooled efficacy of antipsychotics for agitation and psychosis in dementia is biased when based on trials that included patients without these target symptoms or on results measured with generic scales. This finding is important for reviewers and guideline developers who select trials for reviews.

Behavior and Evolution of Young ONset Dementia part 2 (BEYOND-II) study: an intervention study aimed at improvement in the management of neuropsychiatric symptoms in institutionalized people with young onset dementia.

ABSTRACTBackground:Both neuropsychiatric symptoms (NPS) and psychotropic drug use (PDU) are common in institutionalized People with Young Onset Dementia (PwYOD) and can produce negative outcomes such as reduced quality of life and high workload. In community-dwelling PwYOD, NPS are found to be associated with unmet care needs. This emphasizes the importance of a care program for the management of NPS in institutionalized PwYOD that also addresses unmet care needs and PDU. The objectives of the Behavior and Evolution of Young ONset Dementia part 2 (BEYOND-II) study are to develop a care program for the management of NPS in institutionalized PwYOD and to evaluate its effectiveness. METHODS: The care program consists of an educational program combined with an intervention to manage NPS with the following five steps: the evaluation of psychotropic drug prescription, detection, analysis (including the detection of unmet needs), treatment and the evaluation of NPS. A stepped wedge design will be used to evaluate its effectiveness. The primary outcomes are agitation and aggression and other NPS. The secondary outcomes are PDU, quality of life, the workload of nursing staff and job satisfaction. Additionally, a process analysis and a cost-consequence analysis will be conducted. CONCLUSIONS: The study protocol of the Beyond-II study describes the development, implementation and evaluation of a care program for the management of NPS in institutionalized PwYOD. This care program provides a structured method for the management of NPS, in which unmet needs and PDU are also addressed.

The cost-effectiveness of grip on challenging behaviour: an economic evaluation of a care programme for managing challenging behaviour.

OBJECTIVE: The objective of the study was to evaluate the cost-effectiveness of implementing the Grip on Challenging Behaviour care programme (GRIP) on dementia special care units in comparison with usual care. METHODS: A stepped wedge design was used. Challenging behaviour and quality of life were measured using the Cohen Mansfield Agitation Inventory (CMAI) and the QUALIDEM. Quality-adjusted life years (QALYs) were calculated using the EuroQol-5D. Psychoactive medication use (range 0-5 per measurement) and sick leave were registered. Costs included medication, time spent on challenging behaviour and education. Costs and effects were analysed using linear multilevel regression. Incremental cost-effectiveness ratios were calculated. Statistical uncertainty was estimated using bootstrapping. RESULTS: Seventeen dementia special care units participated. GRIP led to improvement on the QUALIDEM subscale social relations (1.6; 95% CI 0.18 to 3.4) and on the use of psychoactive medication (-0.73; 95% CI -1.1 to -0.46) and to a decrease in QALYs (-0.02; 95% CI -0.06 to -0.003). No significant effects on CMAI, sick leave and other QUALIDEM subscales were found. The intervention was not cost-effective in comparison with usual care with regard to CMAI score, QALYs and sick leave. The willingness to pay should be 320€/point improvement on the QUALIDEM subscale social relations and 370€/psychoactive medication less to reach a 0.95 probability of cost-effectiveness. CONCLUSION: It depends on how much society is willing to pay whether GRIP can be considered cost-effective. Because the appropriateness of the current methods for analysing cost-effectiveness in this specific population is uncertain, the positive effects on behaviour, medication and job satisfactions should also be taken in account in the decision making.

Coming to grips with challenging behaviour: a cluster randomised controlled trial on the effects of a new care programme for challenging behaviour on burnout, job satisfaction and job demands of care staff on dementia special care units.

BACKGROUND: Caring for people with dementia in dementia special care units is a demanding job. Challenging behaviour is one of the factors influencing the job satisfaction and burnout of care staff. A care programme for the challenging behaviour of nursing home residents with dementia might, next to diminishing the challenging behaviour of residents, improve job satisfaction and reduce the care staff's feelings of burnout. OBJECTIVES: To determine the effects of a care programme for the challenging behaviour of nursing home residents with dementia on the burnout, job satisfaction and job demands of care staff. DESIGN: The care programme was implemented according to a stepped wedge design in which care units were randomly divided over five groups with different time points of starting with implementation. SETTING: 17 Dutch dementia special care units. PARTICIPANTS: Care staff members of the 17 units. INTERVENTION: The care programme consists of an education package and of various structured assessment tools that guide professionals through the multidisciplinary detection, analysis, treatment and evaluation of treatment of challenging behaviour. METHODS: Burnout, job satisfaction and job demands were measured before implementation, halfway through the implementation process and after all the care units had implemented the care programme. Burnout was measured with the Dutch version of the Maslach burnout inventory (UBOS-C, three subscales); job satisfaction and job demands were measured with subscales of the Leiden Quality of Work Questionnaire. Mixed model analyses were used to determine effects. Care staff could not be blinded for the intervention. RESULTS: Of the 1441 questionnaires, 645 were returned (response 45%, 318 control measurements, 327 intervention measurements) by 380 unique care staff members. Significant effects were found on job satisfaction (0.93, 95% CI 0.48-1.38). On the other outcomes, no significant changes in the scores were found. CONCLUSION: Positive effects of using the Grip on Challenging behaviour care programme were found on job satisfaction, without an increase in job demands.

Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes.

OBJECTIVES: To optimize care and interventions to improve care, and to reduce staff burden, it is important to have knowledge of the relation between individual neuropsychiatric symptoms and distress of care staff. We therefore explored the relation between frequency and severity of individual neuropsychiatric symptoms and distress of care staff. DESIGN: This is an explorative study with a cross-sectional design. PARTICIPANTS AND SETTING: Care staff was interviewed regarding 432 residents of 17 nursing homes for people with dementia. MEASUREMENTS: Behavioural problems were assessed using the Nursing Home version of the Neuropsychiatric Inventory (NPI-NH) questionnaire. The distress scale of the NPI-NH was used to determine the distress of care staff. RESULTS: Agitation/aggression had the highest mean distress score and was also the most prevalent symptom. Disinhibition and irritability/lability also had high mean distress scores, whereas euphoria/elation, hallucinations and apathy had the lowest mean distress score. The symptom severity of each symptom strongly predicted the distress score, whereas the frequency of the symptoms was a less important factor. CONCLUSIONS: Although some of these findings are in accordance with studies among informal caregivers, there are also notable differences. Apathy caused little distress among care staff. Therefore, care staff might not feel the urgency to explore the causes of this symptom. The findings of this study emphasize the importance of supporting care staff in the management of behavioural problems, especially aggression and apathy.

[Meagre evidence so far for effectiveness of in-home comprehensive geriatric assessment: a literature review]. / Bewijs voor effectiviteit van Comprehensive Geriatric Assessment in de thuissituatie nog mager: een literatuurreview.

BACKGROUND: Most elderly people attach great value to staying functionally independent for as long as possible. A targeted detection and treatment of factors that threaten functional independence, through comprehensive geriatric assessment, might promote this. This paper describes a review on the effect of in-home comprehensive geriatric assessment. METHODS: A search was carried out in Pubmed (1977-2012) for randomized controlled trials investigating the effectiveness of multidisciplinary multidimensional in-home geriatric assessment. Data was extracted about effectiveness, costs and factors that had a positive or negative influence on the outcome of CGA. RESULTS: Nine RCTs could be included in the study. All studies were of moderate to good quality, except for one study of poor quality. A positive effect was found in three out of six studies on functional status and in two out of four studies on quality of life. No effect was found on number of hospital admissions, nursing home admissions and on mortality. Most studies showed a rise in total health care expenditure. CONCLUSION: In-home CGA has a modest positive effect on functional status and quality of life. Evidence suggest that in-home CGA might be most effective in elderly that have a relatively high level of functioning.

[Stroke patients in need of long-term nursing home care. Who are they? What are their problems? Which care do they receive?]. / CVA-patiënten die aangewezen zijn op langdurige verpleeghuiszorg. Wie zijn ze? Met welke problemen kampen zij? Welke zorg ontvangen ze?

BACKGROUND AND OBJECTIVE: Many patients who suffer from an acute stroke, will need long-term nursing home care. We are poorly informed about the demographic and clinical characteristics and about the care problems and received care of these patients. This study aims to provide a first description of these characteristics in this group of patients. METHODS: Data on demographic and health-related characteristics, social participation and received care were collected with the Minimum Data Set of the Resident Assessment Instrument, from january 2004-march 2007, in patients who needed long-term nursing home care. Data were collected in eight nursing homes at admission and six months after admission. RESULTS: Many patients were functionally impaired, suffered from depressive symptoms and pain, and were cognitively impaired. In addition, decisional capacity was frequently diminished. The majority of patients were residing at somatic wards, even when severe cognitive impairment was present, such as dementia. Several forms of restraints were frequently used, also at somatic wards. About 40% of the patients, mostly residing at somatic wards, received paramedical treatment. Social engagement was low and was correlated with functional impairment. CONCLUSIONS: Stroke patients who need long-term nursing home care suffer from problems in several domains. The high prevalence of cognitive impairment in stroke patients residing at somatic wards, combined with the ample use of restraints on these wards, raises questions about the appropriateness of the currently delivered care to these patients, considering the problems they have.

Prevalence and correlates of anxiety among nursing home patients.

BACKGROUND: Very little is known about the prevalence and correlates of anxiety among nursing home patients. The current knowledge is predominantly based on information from population-based studies among elderly. METHODS: Prevalence of anxiety was measured with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) in a sample of 333 nursing home patients of somatic wards of 14 nursing homes in the Netherlands. Participants were over 55 years, had a MMSE-score >14 and were able to communicate sufficiently. Information about demographic, health-related, psychosocial and care-related characteristics was collected in interviews with participants and from attending physicians and nursing home staff. RESULTS: The prevalence of anxiety disorders was 5.7%, of subthreshold anxiety disorders 4.2% and of anxiety symptoms 29.7%. Only health-related characteristics (MMSE-score >23, depression, stroke) were significantly associated with anxiety disorders and subthreshold anxiety disorders. Demographic (>6 years education), health-related (depression, impaired vision, pain) and psychosocial characteristics (a recent negative life event) were significantly associated with anxiety symptoms. No care-related characteristics were associated with anxiety. LIMITATIONS: The study population is a selective one (>55 years, MMSE >15, able to communicate sufficiently). The data were collected cross-sectionally. CONCLUSIONS: Anxiety disorders and anxiety symptoms occur frequently among nursing home patients and are mainly associated with health-related characteristics. Physicians should focus special attention on patients with depression or stroke.

[Anxiety disorders in nursing homes: a literature review of prevalence, course and risk indicators]. / Angststoornissen bij verpleeghuisbewoners: een literatuuronderzoek naar prevalentie, beloop en risico-indicatoren.

Psychiatric disorders such as dementia and depression are highly prevalent in nursing homes. The prevalence of anxiety disorders is less clear. Prevalence, course and risk-indicators of anxiety disorders among nursing home residents were examined, based on a review of the literature. Medline and PsychINFO searches were conducted for 1966-2002. Twelve studies were considered relevant. These differed substantially with respect to study-population, diagnostic instruments and diagnostic criteria that were used and the specific anxiety disorders investigated. The prevalence of anxiety disorders ranged from 0-20%. Only in one study the course of anxiety disorders was investigated. About 60% of the nursing home residents recovered in one year. The most important risk-indicators for anxiety disorders identified were: female sex, depression, lack of social support, poor physical health and functional and cognitive impairments. Generalization of these results to the Dutch nursing home population is restricted by the substantial heterogeneity of the studies. Further studies are required to provide reliable estimates of prevalence, course and risk-indicators of anxiety disorders among nursing home residents using appropriate diagnostic instruments and adjusted diagnostic criteria. This will enhance detection and improve treatment of anxiety disorders among nursing home residents.