Process evaluation of the implementation of the ABC method, an intervention for nurses dealing with challenging behaviour of patients with brain injury.

BACKGROUND: Introducing new working methods is common in healthcare organisations. However, implementation of a new method is often suboptimal. This reduces the effectiveness of the innovation and has several other negative effects, for example on staff turnover. The aim of the current study was to implement the ABC method in residential departments for brain injured patients and to assess the quality of the implementation process. The ABC method is a simplified form of behavioural modification based on the concept that behaviour operates on the environment and is maintained by its consequences. METHODS: Four residential departments for brain injured patients introduced the ABC method sequentially as healthcare innovation using a stepped-wedge design. A systematic process evaluation of the implementation was carried out using the framework of Saunders et al. Descriptive statistics were used to analyse the quantitative data; open questions were clustered. RESULTS: The training of the ABC method was well executed and the nursing staff was enthusiastic and sufficiently involved. Important aspects for successful implementation had been addressed (like a detailed implementation plan and implementation meetings). However, facilitators and barriers that were noted were not addressed in a timely manner. This negatively influenced the extent to which the ABC method could be properly learned, implemented, and applied in the short and long term. CONCLUSIONS: The most challenging part of the introduction of this new trained and introduced method in health care was clearly the implementation. To have a successful implementation serious attention is needed to tailor-made evidence-based implementation strategies based on facilitators and barriers that are identified during the implementation process. Bottlenecks in working with the ABC method have to be addressed as soon as possible. This likely requires 'champions' who are trained for the job, next to an organisation's management that facilitates the multidisciplinary teams and provides clarity about policy and agreements regarding the training and implementation of the new method. The current process evaluation and the recommendations may serve as an example for the implementation of new methods in other healthcare organisations.

Efficacy and safety of amantadine as a treatment for apathy after brain injury: Two single-case experimental design studies.

Studies on the efficacy of amantadine as a treatment for apathy after brain injury are scarce and of low quality. We examined the efficacy and safety of amantadine for treatment of apathy in two individuals with brain injury.Two double-blind, randomized, single-case experimental (baseline-amantadine-placebo-withdrawal) design (SCED) studies. Apathy measures included a Visual Analogue Scale (VAS), the Neuropsychiatric Inventory (NPI) apathy subscale and the Behavior Rating Inventory of Executive Function for Adults "Initiate" subscale. Safety measures included a rating scale of possible side effects of amantadine and physical examinations.No difference in apathy symptoms (VAS) between baseline and amantadine phase was found in case 1 (NAP = 0.55). Surprisingly, in case 2, apathy symptoms deteriorated from baseline to amantadine phase (NAP = 0.28, 90% CI = -0.69 to -0.20) and improved from amantadine to placebo phase (NAP = 0.92, 90% CI = 0.60-1.00). This improvement was also found on the NPI apathy subscale. Side effects of amantadine were observed in case 2.In this SCED study, amantadine did not improve apathy symptoms in two individuals with brain injury. However, this study shows that side effects of amantadine can occur which lead to a significant decrease in well-being. More high quality studies are required.

Exploring Perceived Interactions Between Consequences of Traumatic Brain Injury.

OBJECTIVE: To explore the perceived interactions between consequences of traumatic brain injury (TBI). PARTICIPANTS: Fifteen clinicians experienced in working with patients with TBI. METHODS: Participating clinicians completed an online questionnaire in which they estimated the degree to which consequences of TBI (taken from the Brief ICF Core Set for Traumatic Brain Injury) causally relate to each other. Based on these perceived interactions, a visual network was constructed and centrality measures for this network were computed. RESULTS: The resulting network demonstrates various strong perceived causal relations between the consequences of TBI. Impairments in consciousness were perceived to most strongly cause other TBI consequences in the network. Difficulties with acquiring, keeping, and terminating a job were perceived to be most strongly caused by other TBI consequences. Difficulties in partaking in complex interpersonal interactions were also perceived to play a central role in the network. CONCLUSION: In the perception of clinicians, consequences of TBI interact with each other and are thus not solely a direct result of the injury. While more research is needed to map the interactions between consequences of TBI, our results could have important implications for the way we understand and treat the problems patients are faced with after TBI.

Long-Term Effects of a Behavioural Management Technique for Nurses on Aggressive Behaviour in Brain-Injured Patients.

OBJECTIVE: The ABC method (Antecedent events, target Behaviours, Consequent events) is a behavioural management technique developed for nurses. The objective of the present study was to examine the long-term effects of the ABC method on aggressive behaviour in 40 patients with acquired brain injury. METHOD: Four aggression outcome measures and a questionnaire about the implementation of the ABC method were filled out by the nursing staff in this longitudinal intervention study. RESULTS: Contrary to expectations, a significant increase of aggression was found on two aggression measures. A possible explanation may be that the ABC method increased awareness of aggression in the nursing staff. Results of the implementation questionnaire indicated that the ABC method was not part of usual care at the long-term follow-up. CONCLUSIONS: It seems that the quality of the implementation process was insufficient to find an effect of the ABC method on aggression. Suggestions for improving the implementation process are made in this paper.

Psychological interventions for treating neuropsychiatric consequences of acquired brain injury: A systematic review.

Anxiety, aggression/agitation, apathy and disinhibition are common neuropsychiatric consequences of acquired brain injury (ABI); these consequences can cause functional impairment and lead to reduced social integration. This systematic review aims to provide an examination of the current evidence on psychological interventions for treating these consequences. Two reviewers selected potential relevant articles, retrieved from five literature databases; methodological quality was assessed and appraised. A total of 5207 studies were found, of which 43 were included: 21 studies for anxiety, 18 for aggression, two studies for apathy, and six for disinhibition. Three studies addressed multiple consequences. Four high-quality (i.e., Class I and II) studies showed significant decreases in anxiety after cognitive behavioural therapy (CBT). In total, 14 studies consistently showed significant decreases in aggression/agitation after behavioural management techniques or anger management sessions. Substantial variability existed in the examined interventions and in their effects on apathy and disinhibition. Unfortunately, firm conclusions and recommendations for clinical practice are considered premature, due to concerns about the methodology used. However, this review yielded new evidence on the effectiveness of CBT for anxiety symptoms post-ABI and there has been some response to the ongoing call for studies with high methodological quality.

Associations of fat and muscle tissue with cognitive status in older adults: the AGES-Reykjavik Study.

Background/Objective: studies on the association of dementia with specific body composition (BC) components are scarce. Our aim was to investigate associations of BC measures with different levels of cognitive function in late-life. Methods: we studied 5,169 participants (mean age 76 years, 42.9% men) in the AGES-Reykjavik Study of whom 485 (9.4%) were diagnosed with mild cognitive impairment (MCI) and 307 (5.9%) with dementia. Visceral fat, abdominal and thigh subcutaneous fat, and thigh muscle were assessed by computed tomography. MCI and dementia were based on clinical assessment and a consensus meeting; those without MCI or dementia were categorised as normal. Multinomial regression models assessed the associations stratified by sex and in additional analyses by midlife body mass index (BMI). Results: among women, there was a decreased likelihood of dementia per SD increase in abdominal subcutaneous fat (OR 0.72; 95% CI: 0.59-0.88), thigh subcutaneous fat (0.81; 0.67-0.98) and thigh muscle (0.63; 0.52-0.76), but not visceral fat, adjusting for demographics, vascular risk factors, stroke and depression. Inverse associations of fat with dementia were attenuated by weight change from midlife and were strongest in women with midlife BMI <25. In men, one SD increase in thigh muscle was associated with a decreased likelihood of dementia (0.75; 0.61-0.92). BC was not associated with MCI in men or women. Conclusion: a higher amount of abdominal and thigh subcutaneous fat were associated with a lower likelihood of dementia in women only, while more thigh muscle was associated with a lower likelihood of dementia in men and women.

Both Low and High 24-Hour Diastolic Blood Pressure Are Associated With Worse Cognitive Performance in Type 2 Diabetes: The Maastricht Study.

OBJECTIVE: Hypertension and diabetes are both risk factors for cognitive decline, and individuals with both might have an especially high risk. We therefore examined linear and nonlinear (quadratic) associations of 24-h blood pressure (BP) with cognitive performance in participants with and without type 2 diabetes. We also tested the association of nocturnal dipping status with cognitive performance. RESEARCH DESIGN AND METHODS: This study was performed as part of the Maastricht Study, an ongoing population-based cohort study. Cross-sectional associations of 24-h BP (n = 713, of whom 201 had type 2 diabetes) and nocturnal dipping status (n = 686, of whom 196 had type 2 diabetes) with performance on tests for global cognitive functioning, information processing speed, verbal memory (immediate and delayed word recall), and response inhibition were tested using linear regression analysis and adjusted for demographics, vascular risk factors, cardiovascular disease, depression, and lipid-modifying and antihypertensive medication use. RESULTS: After full adjustment, we found quadratic (inverted U-shaped) associations of 24-h diastolic blood pressure (DBP) with information processing speed (b for quadratic term = -0.0267, P < 0.01) and memory (immediate word recall: b = -0.0180, P < 0.05; delayed word recall: b = -0.0076, P < 0.01) in participants with diabetes, but not in those without. No clear pattern was found for dipping status. CONCLUSIONS: This study shows that both low and high 24-h DBP are associated with poorer performance on tests of information processing speed and memory in individuals with type 2 diabetes.

Temporal evolution of cognitive changes in incident hypertension: prospective cohort study across the adult age span.

Midlife hypertension is a risk factor for dementia, but little is known about the cognitive trajectories of individuals with incident hypertension. This study follows the cognitive functioning in prevalent and incident hypertension for 12 years and in relation to age and treatment status. Cognitively intact adults aged 25 to 84 years (n=1805) were serially assessed at baseline, 6 years, and 12 years. Hypertension was defined by sphygmomanometry or antihypertensive medication use, and its association with cognitive decline was tested in random-effects models. At baseline, 638 (35.3%) participants had hypertension. They showed faster decline in memory (χ(2) test for homogeneity=35.75; df=2; P<0.001), executive functions (χ(2)=21.68; df=2; P<0.001), and information processing speed (χ(2)=81.96; df= 2; P<0.001) than baseline normotensive participants. At follow-up, 352 individuals (30.2%) developed incident hypertension. They showed faster decline in memory (χ(2)=7.88; df=2; P=0.019) and information processing speed (χ(2)= 18.06; df=2; P<0.001), especially from 6- to 12-year follow-up. Effects were most pronounced and widespread in midlife for both prevalent and incident hypertension and in those with untreated and uncontrolled hypertension. This study shows that incident hypertension predicts cognitive decline in middle-aged individuals, and those with poorly controlled blood pressure are most at risk. In newly diagnosed individuals, decline evolves gradually, possibly opening a window for early intervention.

Effects of type 2 diabetes on 12-year cognitive change: results from the Maastricht Aging Study.

OBJECTIVE: To examine the effects of baseline and incident diabetes on change in cognitive function over 12 years. RESEARCH DESIGN AND METHODS: A sample of 1,290 individuals aged ≥ 40 years at baseline, participating in the Maastricht Aging Study, were cognitively tested at baseline, after 6 years, and after 12 years. Of these, 68 participants had type 2 diabetes at baseline, and 54 and 57 had incident diabetes at the 6- and 12-year follow-up, respectively. Changes in performance on tests of information-processing speed, executive function, and verbal memory from baseline to 6- and 12-year follow-up were compared between groups using linear mixed models. Effects of diabetes on cognitive decline were adjusted for demographic variables, history of smoking, alcohol intake, and comorbid conditions, including hypertension, cardiovascular disease, BMI, and depression. RESULTS: Participants with baseline diabetes showed larger decline in information-processing speed (estimate -7.64; P < 0.01), executive function (21.82; P < 0.01), and delayed word recall (-1.35; P < 0.05) over the 12-year follow-up compared with control subjects. No significant difference in decline was observed for immediate word recall. Compared with control subjects, participants with incident diabetes showed subtle early decline in information-processing speed only. Interestingly, they did not show larger decline in any other cognitive domain. CONCLUSIONS: Individuals with baseline type 2 diabetes show accelerated cognitive decline, particularly in information-processing speed and executive function, compared with individuals without diabetes. In incident diabetes, decline in speed becomes detectable first, and cognitive decline seems to increase with increasing exposure time.