BPSD in dementia patients
Introduction
The management of behavioral and psychological symptoms of dementia has proven to be a daunting task for healthcare professionals. A mixture of approaches based on behavioral theories and pharmacological interventions have been used to control these neuropsychiatric symptoms with mixed results (de Ven et al., 2012). Dementia-Care mapping (DCM) is a multi-component intervention based on the social-psychological theory of dementia by Kitwood. It was developed in 1992 by the Dementia research group at Bradford University. DCM is posited to provide a holistic person-centered approach to the care of patients with dementia. Kitwood’s theory postulates that neuropsychiatric symptoms in patients with dementia are attributable to negative environmental influences which encompass amongst other factors inadequate care practices and staff attitudes. DCM thus incorporates a number of interventions aimed at the staff, residents, management and the organization (de Ven et al., 2012). This study seeks to address the questions of whether the DCM approach to care of dementia patients helps to:
i) Lower the frequency and intensity of the behavioral and psychological symptoms of dementia.
ii) Improves the quality of life of patients with dementia
iii) Reduces job-related stress associated with caring for patients with dementia.
iv) Improves job satisfaction for nursing staffs caring for dementia patients.
As such it is purposed to provide an evidence base to support the use of DCM in the care of patients with dementia, to enhance staff-patient interactions, improve the quality of life of these patients and to reduce the use of pharmacological interventions in the treatment of dementia-induced neuropsychiatric symptoms.
Literature review
The prevalence of behavioral and psychological symptoms of dementia (BPSD) amongst dementia patients admitted in nursing homes is approximately 80% (de Ven et al., 2012). These neuropsychiatric symptoms affect the quality of life of the patients and at the same time portend a major challenge to professional caregivers. Their etiology is thought to be a mixture of environmental influences such as impersonalized institutional settings and staff attitudes. They have been inextricably linked with high job dissatisfaction amongst workers which leads to increased absenteeism and high turnover rates and subsequently staff shortages. High turnover rates have on the other hand been associated with poor resident outcomes such as poor quality of life.
It has been posited that education of staffs on how to manage BPSD in dementia patients reduces albeit to some extent these neuropsychiatric symptoms and subsequently the use of pharmacological interventions to control them. However, the findings elicited by clinical studies on the issue have largely been inconsistent. A study by Visser et al (2006, p. 47) found that staff education resulted in no improvements in BPSD or quality of life of the patients. Another study by Deudon et al (2009, p. 1386) arrived at opposite results. Notably, the interventions implemented in majority of these studies were either staff or resident focused and hence were limited in scope considering that these neuropshychiatric symptoms have a mixed etiology (Kolawaski et al, 2010, p. 215). DCM encompasses a number of interventions aimed at the staff, residents, management and organization and hence may be more beneficial than the single interventions. The DCM approach entails making continuous improvements to patient care plans on the basis of systematic observations made during actual care delivery in nursing homes or other care settings. Feedback is provided to staffs with the aim of enhancing their awareness on the interdependency between their individual behaviors and those of the patients under their care. This feedback is provided in a non-threatening manner and is not part of a staff’s performance appraisal. Both negative and positive events are captured during observations and are used to encourage staff to work on improving their competencies (de Ven, 2012).
Sampling
The sample for the study will comprise of dementia patients residing in nursing homes and the nursing professional caring for them. These nursing homes will be selected randomly from a list of all such homes in the area. The inclusion criteria for residents will include, residents aged 65 years or more, diagnosed with dementia as per the DSM-IV criteria, consents to the study voluntarily or alternatively consent is provided by significant others, exhibits at least one of a batch of designated neuropsychiatric symptoms that is aggression, psychosis, apathy, depression, motor or verbal agitation and lastly, uses common areas for a minimum of 4 hours in a day. Dementia patients with a short life expectancy (6 weeks or less), those who fail to consent to the study and those who are unable to access common areas on account of physical impairments will be excluded from the study. All nurses working at these homes are eligible for the study.
Study methods
The study will be a randomized controlled clinical trial with no blinding. The nursing homes will be randomized to an intervention and a control group. Assessments will be conducted pre-intervention and following each DCM cycle. Staff satisfaction and job-related stress will be assessed at baseline and at the end of the study.
Study procedures
Randomization
Before randomization, the directors of the nursing homes will be approached; information about the study provided and consent for conducting the study in their institutions sought. Two homes will be randomized to the intervention group and the other two to the control group. Randomization at the nursing level is meant to avoid contamination bias that may result from exchange of information between staffs in the nursing homes. Consideration will be given to the number of dementia patients and the staff-patient ratios in the various homes during randomization.
Interventions
Staff members in the intervention group will undergo a 4-day training course on the basic concepts and skills of DCM. Two nurse managers from each intervention institution will undergo a further 3-day training course on the theory and background of DCM to become advanced DCM users. The four individuals will be in-charge of supervising other staffs, mapping care, reporting observations, championing DCM in their respective institutions, providing feedback and facilitative support to other staffs. After the training, one-day long visits will be made to each intervention nursing home and an organization wide 1-day training course provided. The latter training is purposed to provide a basic understanding of DCM in the organization and thus foster commitment for the implementation of DCM. Following the DCM training, two DCM cycles will be carried out in the intervention nursing homes. A basic DCM cycle consists of observation, provision of feedback and development of action plans which are then implemented. Participants in the control group will not receive DCM training and residents in this group will continue to receive usual care.
Data collection
Both patient and staff outcomes will be measured. The demographics of the patients and the staff will be measured using questionnaires at the beginning of the study. Patient’s agitation will be measured using Cohen-Mansfield Agitation Inventory (CMAI). The quality of life of the patient will be measured using Alzheimer’s Disease Related Quality of Life (ADRQL) scale by Black, Rabins & Kasper (2000). Maslack Burnout Inventory (MBI) by Maslack, Jackson & Leiten (1996) will be used to measure staff burnout. Job satisfaction will be measured using the Maastricht Job Satisfaction Scale for Healthcare. The latter four aspects will be measured at baseline and after the first and second DCM cycles.
Data analysis
The scores obtained using the various scales will be analyzed using mixed ANOVA with time and DCM training as the within factors. Multiple regression analysis will be done to eliminate any confounding between variables.
A key strength of the study lies in its ability to measure the implementation of the plans of actions developed following observations of staff-patient interactions. On limitations, the quality of life and patient’s agitation will be assessed by the staff in the nursing homes who will also have in the case of the intervention groups received DCM training. There is a possibility for these staffs to be biased when rating the behavioral symptoms of the patients hence this is a potential limitation of the study.
Clinical relevance
The findings of this study will be useful for nursing staffs working in nursing home, the management of nursing homes, and the persons in charge of preparing curriculums in geriatrics because they will provide an evidence base for their decision making and practice.
References
Chenoweth, L., King, M.T., Jeon, M.H., Brodaty, H., Stein-Parbury, J., Norman, R., Haas, M., &
Luscombe, G. (2009). Caring for aged dementia care resident study (CADRES) of
person-centred care, dementia-care mapping, and usual care in dementia: A cluster
randomised trial. Lancet Neurol., 8(5), 419.
Deudon, A., Maubourget, N., Gervais, X., Leone, E., Brocker, P., Carcaillon, L., Riff, S.,
Lavallart, B., & Robert, P. H. (2009). Non-pharmacological management of
behavioral symptoms in nursing homes. Int J Geriatr Psychiatry, 24, 1386-1395.
de Ven, G., Draskovic, I., Adang, E.M., Donders, R.A., Post, A., Zuidema, S.U.,
Koopmans, R.
T., & Vernooij-Dassen, M. J. (2012). Improving person-centered care in nursing homes
through dementia-care mapping: Design of a cluster-randomised controlled trial. BMC
Geriatr. 12 (1).
Jeon, Y. H., Luscombe, G., Chenoweth, L., Stein-Parbury, Brodaty, H., King, M., & Haas, M.
(2011). Staff outcomes from the caring for aged dementia care resident study (CADRES):
A cluster randomized trial. International journal of Nursing Studies. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/22078076
Kolanawski, A., Fick, D., Frazer, C., & Penrod, J. (2009). It’s about time: Use of non-
pharmacological interventions in the nursing homes. Journal of Nursing Scholarship,
42(2), 214-222.
Visser, S.M., Mccabe, M.P., Hudgson, C., Buchanan, G., Davison, T.E., & George, K. (2006).
Aging and Mental Health, 12(1), 47-55.
