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• W2300967455 abstract "The review article in this issue of the Journal of the American Geriatrics Society by Jutkowitz and colleagues, “Care-Delivery Interventions to Manage Agitation and Aggression in Nursing Home and Assisted Living Residents with Dementia: A Systematic Review and Meta-Analysis,” is timely in view of recent national efforts to reduce the use of antipsychotic medications for nursing home residents whose main indication is dementia with behavioral disturbances.1 The prevalence of antipsychotic medication use in short- and long-stay nursing home residents is one of several quality measures on the Centers for Medicare and Medicaid Services (CMS) publicly available, five-star rating system (http://www.medicare.gov/nursinghomecompare). Furthermore, a reduction in the prevalence of antipsychotic medications in nursing homes is part of the current CMS-issued Scope of Work for state Quality Improvement Organizations (QIOs) nationwide. Thus, there is considerable pressure on nursing home staff to reduce their use of antipsychotic medications to manage behavioral disturbance in residents. As noted in the review article, the use of nonpharmacological interventions is now recommended in clinical practice guidelines as first-line treatment for behavioral disturbances in older adults with dementia because of evidence that there are significant health risks associated with the use of antipsychotic medications. In addition, it is widely purported that nonpharmacological interventions can reduce the need for pharmacological treatments, with low risk of side effects. Unfortunately, this systematic review article reaches the sobering conclusion that there is not currently defensible evidence that nonpharmacological interventions are effective in reducing agitation or aggression in nursing home or assisted-living residents with dementia.1 In light of the existing literature, we agree with this conclusion despite our enthusiasm for nonpharmacological intervention approaches based on our training as behavioral psychologists and evidence that such interventions are effective in older nursing home residents with and without dementia in improving other aspects of behavior and functioning.2, 3 There are two important points related to the potential value of nonpharmacological interventions, neither of which is often acknowledged in research studies. First, efficacious nonpharmacological interventions typically require consistent, supportive interactions between the resident and other trained person(s). These interactions can have important quality-of-life benefits beyond change in the targeted behavior. Second, nonpharmacological interventions to manage problem behaviors have proven effective in other populations (e.g., children and adults with autism-spectrum disorders), which lends support to the rationale that similar interventions could be effective for managing behavioral problems associated with dementia.4 Nevertheless, to determine the potential applicability of nonpharmacological interventions in nursing homes and assisted-living facilities, it is important to understand the requirements of an efficacious intervention in other settings. Most notably, an efficacious intervention targeted at managing a problem behavior must be implemented with a high degree of consistency so that the target behavior (e.g., physical or verbal aggression) is reacted to in the same way each time it occurs or the alternative desirable behavior (e.g., cooperation with care) is supported in the same way each time it occurs. This consistency is difficult to accomplish and requires a high degree of training, as well as a therapist or caregiver who knows the person well. Given the high rate of staff turnover in nursing homes at all levels, but most importantly at the direct caregiver level (nurses’ aide), and studies that suggest that there may not be sufficient nurses’ aides to consistently provide multiple aspects of daily care (e.g., toileting, feeding, mobility assistance), it is likely that many nursing homes do not have the direct caregiver capacity to implement effective nonpharmacological interventions consistently in daily care practice.5-7 Such consistency would further require critical staff on all shifts (weekdays, weekends; day, evening, night) to be competent in the implementation of the intervention. In addition, even effective nonpharmacological interventions often do not result in immediate effects, which can be problematic if a resident's behavior is highly disruptive to other residents or staff. It is likely that the staff training and resource demands of consistently implementing effective nonpharmacological interventions combined with the need to manage a disruptive resident explain why medications are more often used as first-line treatment rather than nonpharmacological approaches, despite the associated risks of antipsychotics. The article by Jutkowitz and colleagues provides some insights into the important elements of future research to better inform the potential use of nonpharmacological interventions to manage behavioral disturbances in nursing home or assisted-living residents with dementia.1 One such recommendation is that dedicated, trained staff whose primary responsibility is implementation implement nonpharmacological interventions under controlled conditions to ensure intervention fidelity. This approach requires a precise definition of the critical intervention care processes, also recommended in the article, and objective documentation of resident behaviors and the time necessary to provide the intervention.1 A more-rigorous scientific evaluation of nonpharmacological interventions also should include standardized, objective outcome measures by persons blind to the intervention because placebo effects can significantly influence behavioral ratings. As acknowledged in this review article, nonpharmacological interventions are often multifaceted and individualized to the resident's needs, which creates methodological challenges in evaluation studies, but these challenges are not unique to this area. Older adults typically have multiple care needs (e.g., mobility impairment and incontinence) that require a multifaceted intervention approach, and there are published randomized, controlled trials that demonstrate this type of implementation research.6, 8 In addition, resident characteristics that may be predictive of a person's level of responsiveness to an intervention also can be measured using this approach along with the use of antipsychotic medications. Other studies have evaluated behavioral interventions combined with medication in nursing home residents to treat other clinical conditions.9, 10 Studies to determine whether antipsychotics can be reduced in dosage or frequency of delivery when combined with a nonpharmacological intervention are worth exploring and might be more feasible in practice than eliminating these medications altogether. It also will likely be necessary in future studies to consider the total 24-hour care environment of nursing home and assisted-living residents. It was not clear from the review article whether any of the nonpharmacological interventions extended to nighttime hours, for example, even though there is substantial evidence of noise and sleep disruption in nursing homes at night.11 Nighttime noise and sleep disruption could trigger or exacerbate behavioral disturbances in residents with dementia during nighttime and daytime hours. A more-systematic evaluation of nonpharmacological interventions, as Jutkowitz and colleagues and the authors of this editorial recommend, would provide the critical information necessary to identify effective intervention care processes and the labor resource requirements to implement these processes consistently in care practice. This valuable information then could be used to inform nursing homes and assisted-living facilities of what is reasonable for them to achieve given their staff resources. Other studies have demonstrated the need for and clinical utility of structured targeting criteria for behavioral interventions so that limited staffing resources can be allocated to those who are likely to benefit most from the intervention.7, 12 Finally, it may be easier to prevent the development of behavioral disturbances in individuals with dementia than to treat it when it occurs, although there are sparse data to support this hypothesis. For example, preventative interventions that improve the transition of residents to new rooms within the facility or acclimation to a new care environment upon admission and interventions that improve nighttime sleep and daytime activity engagement all could be defended as targeting factors known to be associated with behavioral disturbances or, minimally, delirium.13, 14 It is likely that such preventative interventions would need to be multifaceted and thus require an organized research effort to be evaluated defensibly. Despite the numerous challenges, efforts to implement and evaluate nonpharmacological approaches to managing behavioral disturbances in individuals with dementia are worthwhile. In contrast to medications, nonpharmacological approaches should have minimal to no unintended negative side effects and the potential to improve a resident's functioning in multiple domains, including quality of life. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors critically analyzed and wrote the editorial. Sponsor's Role: None." @default.
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• W2300967455 title "Managing Agitation and Aggression in Congregate Living Settings: Efficacy and Implementation Challenges" @default.
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