Behavioural management in nursing and residential homes: a randomised controlled trial

doi:10.1016/S0140-6736(98)08237-3

The Lancet

Volume 354, Issue 9172, 3 July 1999, Pages 26-29

https://doi.org/10.1016/S0140-6736(98)08237-3 Get rights and content

Summary

Background

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.

Methods

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.

Findings

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.

Interpretation

Elderly residents can benefit from improved quality of care achieved by training from a hospital outreach team.

Introduction

In the UK, the move towards community-based care has resulted in substantial changes in the provision of long-term care facilities for elderly people. The decrease in numbers of long-stay NHS beds has been countered by a rise in the number of highly dependent elderly people in other care settings.¹ Psychiatric morbidity and physical disability are increasing in independent nursing and residential homes, as is the prevalence of dementia.2, 3, 4, 5 Staff in nursing and residential homes receive minimal training in caring for individuals whose needs might have warranted hospital admission in the past.² The poor quality of life for elderly residents is well known, with many accounts of poor care standards and rigid institutional regimens.6, 7

In the future, with increasing demand and restricted resources, improvement must occur in standards of staff training, facilities, frequency of specialist advice, and support provided to nursing and residential homes.⁸ This improvement is unlikely to occur while suitable medical and nursing skills are concentrated in hospitals.³ A reappraisal is needed of the way in which resources and skills are used if there are to be any positive changes in the quality of care. Despite this, little research has been done in the UK to assess the effects of support services on the quality of care in nursing and residential homes. We assessed the effect of an old-age psychiatry outreach team on quality of care by means of a randomised controlled trial.

Section snippets

Recruitment

Our study took place in nursing and residential homes in south Manchester, UK. Full ethical approval was obtained for the project, and consent was obtained from the residents and their relatives. Ten residential homes and two nursing homes participated, and were paired according to size and accreditation status. Computer-generated random numbers were used independently of the researchers to assign one of each pair of homes to the intervention or control group. Ten residents in each home were

Baseline characteristics

120 residents were recruited to the study (figure), 60 in each study group. 105 (87·5%) remained at the 6-month follow-up assessment. 11 residents had died, one had been transferred to hospital, one had been moved to a nursing home, and two had withdrawn consent. Six of the residents lost to follow-up were in the intervention group, and nine were in the control group. Five of the nine controls who did not complete the study were from the same home. After adjustment for clustering effects, the

Discussion

Our main finding was that with a focused intervention, residents were responsive to the intervention used by staff to achieve their goal plans. In weekly sessions over 6 months, staff could be trained to develop skills in assessment and care planning, to implement the programme in everyday care, and to assess the efficacy of the programme in terms of effects on the ways residents functioned. This result is similar to those of Dean, Briggs, and Lindesay¹⁷ in their assessment of the effects of

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Cited by (108)

Experience of professional caregivers and risk of burnout with shouting demented residents in nursing home
2017, NPG Neurologie - Psychiatrie - Geriatrie
La prise en soin des résidents déments crieurs en institution médicosociale est complexe. Les interventions sur les aidants professionnels représentent un des axes de soin car elles permettent de maintenir la relation en diminuant les ressentis négatifs des professionnels et en prévenant un syndrome d’épuisement professionnel des soignants (SEPS). Notre enquête auprès de professionnels de trois EHPAD montrent que l’exposition aux cris répétés des résidents déments entraîne l’apparition de ressentis négatifs favorisant le SEPS. La formation des professionnels, la mise en place de réunions pluridisciplinaires, l’intervention d’une équipe mobile de psychogériatrie ou la constitution de groupes de parole ou d’analyse des pratiques permettraient d’améliorer la prise en charge de ces résidents.
Taking care of shouting demented residents in medicosocial institutions is complex. Interventions with professional caregivers are a component of care provision because they make it possible to sustain the relationship by decreasing negative feelings among professionals and preventing burnout. Our survey conducted among professionals in three geriatric institutions shows that the exposure to repeated shouting by demented residents generates negative feelings that increase the risk of burnout. Training for these professionals, the organisation of multidisciplinary meetings, psychogeriatric mobile team interventions and the development of practice analysis groups could improve the management of these residents.
Shouting in dementia
2015, Presse Medicale
Les cris répétés de la personne atteinte de démence sont des manifestations particulièrement fréquentes en institution et souvent jugées comme extrêmement perturbatrices. Ils restent pourtant le moins bien compris des troubles du comportement.
Le comportement crieur n’a pas forcément le caractère péjoratif tel que défini par les pouvoirs publics et les institutions. Il peut revêtir une multitude de significations et être caractérisé tour à tour de cri « réflexe », cri « comportement », cri « langage », cri « agressif ».
Ces cris ont une causalité multifactorielle pouvant traduire des perturbations organiques ou somatiques, mais également des perturbations psychiques, cognitives et/ou environnementales qu’il faut toujours rechercher.
La méthode des 5W est une des méthodes fiables et facilement utilisables en pratique clinique pour permettre une analyse du comportement crieur chez le sujet affecté par une démence.
On constate encore un recours trop précoce et massif de l’approche pharmacologique dans la prise de charge du comportement crieur chez la personne souffrant d’une pathologie démentielle. Au contraire, il est nécessaire d’utiliser en première intention une approche non pharmacologique basée sur des interventions centrées sur le patient, l’environnement et/ou l’entourage après évaluation minutieuse et multidisciplinaire du cri par l’équipe soignante.
Shouting in dementia is a frequent manifestation in institution and is often considered to be extremely disruptive. It remains the most misunderstood behavioral disorder.
Shouting or screaming is not a necessarily pejorative qualifier as defined by public authorities and institutions. It can take a multitude of meanings and be characterized alternately as a “reflex”, a “behavior”, a “language”, an “aggression”.
Shouting has a multifactorial causation. It can translate organic or somatic disorders, but also psychological, cognitive and/or environmental disturbances that clinicians should look for.
The 5W method is a reliable and easy to use method in clinical practice to allow analysis of shouting in dementia.
There is still too early and massive use of pharmacological approach in taking charge of the repetitive shouts in dementia. Instead, it is necessary to use a first-line non-pharmacological approach based on patient-centered, environment-centered and/or entourage-centered interventions after careful multidisciplinary assessment of this behaviour by the healthcare team.
A new simple score (ABS) for assessing behavioral and psychological symptoms of dementia
2015, Journal of the Neurological Sciences
Citation Excerpt :
Among them, mini-mental state examination (MMSE) and Hasegawa Dementia Score-Revised (HDS-R) are common for screening general cognitive function [2,3]. As for BPSD, behavioral pathology in AD (Behave-AD) was proposed at year 1987 [4], Crichton Geriatric Behavioral Rating Scale (CGBRS) at year 1989 [5,6], Dementia Behavior Disturbance Scale (DBDS) at year 1990 [7], neuropsychiatric inventory (NPI) at year 1994 [8], and Troublesome Behavior Scale (TBS) at year 1994 [9]. Although these previous BPSD scores are well established, all of them were designed for detailed examination and thus usually take time.
In addition to cognitive impairment, behavioral and psychological symptoms of dementia (BPSD) are another important aspect of most dementia patients. This study was designed for a new simple assessment of BPSD. We first employed a clinical survey for the local community with sending an inquiry letter to all members (n = 129) of dementia caregiver society, and then attempted to create a new BPSD score for dementia with 10 BPSD items. This new simple BPSD score was compared to a standard-detailed BPSD score neuropsychiatric inventory (NPI) for a possible correlation (n = 792) and a time to complete (n = 136). Inter-rater reliability was examined comparing scores between main and second caregivers (n = 70) for AD. Based on the clinical survey for local caregivers, a new BPSD score for dementia (ABS, Abe's BPSD score) was newly created, in which each BPSD item was allotted by an already-weighted score (maximum 1–9) based on the frequency and severity, and was finalized with taking temporal occurrences into account. ABS was filled by the main caregiver with a full score of 44, was well correlated with NPI (r = 0.716, **p < 0.01) in 792 AD patients (age 78.6 ± 7.0 years, MMSE 19.0 ± 5.9), and took a shorter time as only 56.8 ± 38.8 s (**p < 0.01) than NPI score (132.7 ± 94.0 s) with 136 AD patients. A high inter-rater reliability was obtained (r = 0.964, **p < 0.01) with a little smaller score (0.877 time) of ABS in secondary than the main caregivers. ABS provides a new simple and quick test for BPSD assessment, with a good correlation to NPI but a shorter time, and with a high inter-rater reliability. Thus ABS is useful for evaluating BPSD for mild to moderate dementia patients.
A structural multidisciplinary approach to depression management in nursing-home residents: A multicentre, stepped-wedge cluster-randomised trial
2013, The Lancet
Depression in nursing-home residents is often under-recognised. We aimed to establish the effectiveness of a structural approach to its management.
Between May 15, 2009, and April 30, 2011, we undertook a multicentre, stepped-wedge cluster-randomised trial in four provinces of the Netherlands. A network of nursing homes was invited to enrol one dementia and one somatic unit per nursing home. In enrolled units, nursing-home staff recruited residents, who were eligible as long as we had received written informed consent. Units were randomly allocated to one of five groups with computer-generated random numbers. A multidisciplinary care programme, Act in Case of Depression (AiD), was implemented at different timepoints in each group: at baseline, no groups were implenting the programme (usual care); the first group implemented it shortly after baseline; and other groups sequentially began implementation after assessments at intervals of roughly 4 months. Residents did not know when the intervention was being implemented or what the programme elements were; research staff were masked to intervention implementation, depression treatment, and results of previous assessments; and data analysts were masked to intervention implementation. The primary endpoint was depression prevalence in units, which was the proportion of residents per unit with a score of more than seven on the proxy-based Cornell scale for depression in dementia. Analyses were by intention to treat. This trial is registered with the Netherlands National Trial Register, number NTR1477.
16 dementia units (403 residents) and 17 somatic units (390 residents) were enrolled in the course of the study. In somatic units, AiD reduced prevalence of depression (adjusted effect size −7·3%, 95% CI −13·7 to −0·9). The effect was not significant in dementia units (0·6, −5·6 to 6·8) and differed significantly from that in somatic units (p=0·031). Adherence to depression assessment procedures was lower in dementia units (69% [SD 19%]) than in somatic units (82% [15%]; p=0·045). Adherence to treatment pathways did not differ between dementia units (43% [SD 33%]) and somatic units (38% [40%]; p=0·745).
A structural approach to management of depression in nursing homes that includes assessment procedures can reduce depression prevalence in somatic units. Improvements are needed in depression screening in dementia units and in implementation of nursing-home treatment protocols generally.
The Netherlands Organization for Health Research and Development.
Reducing depression in nursing homes: So little, so late
2013, The Lancet
A systematic review of staff training interventions to reduce the behavioural and psychological symptoms of dementia
2013, Ageing Research Reviews
Citation Excerpt :
These designs require a higher sample size to be adequately powered and the analysis needs to adjust for clustering effects. Only three studies adjusted for these effects in their sample size calculation (Chenoweth et al., 2009; Fossey et al., 2006; Proctor et al., 1999) or their analysis (Chenoweth et al., 2009; Fossey et al., 2006; Teri et al., 2005). Meanwhile, some of the staff measures may not have been sensitive enough to detect change, or the nature of the change may have been somewhat abstract or difficult to assess with the available quantitative measures.
Behavioural and psychological symptoms of dementia (BPSD) are highly prevalent and problematic in care settings. Given the limited effectiveness of medical treatments, training care staff to understand and manage these symptoms is essential for the safety and quality of life of people with dementia. This review evaluated the effectiveness of staff training interventions for reducing BPSD. A systematic literature search identified 273 studies. Twenty studies, published between 1998 and 2010, were found to meet the inclusion criteria. Overall, there was some evidence that staff training interventions can impact on BPSD: twelve studies resulted in significant symptom reductions, four studies found positive trends and four studies found no impact on symptoms. No links were found between the theoretical orientation of training programmes and their effectiveness. Training was also found to impact on the way staff behaved towards residents. A quality screening, using pre-specified criteria, revealed numerous methodological weaknesses and many studies did not adhere to the recommended guidelines for the conduct of cluster randomised controlled trials. There is an urgent need for more high quality research and evidence-based practice in BPSD.

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ArticlesBehavioural management in nursing and residential homes: a randomised controlled trial

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Recruitment

Baseline characteristics

Discussion

Residential care for elderly people: a decade of change

BMJ

The implications of managing confused and disabled people in non-specialist residential homes for the elderly

Health Trends

Changes in behavioural characteristics of elderly populations of local authority homes and long stay hospital wards

BMJ

Psychiatric illness in elderly residents of part III homes in one London borough: prognosis and review

Age Ageing

Time for action: an observational study of elderly people in four different care environments.

Private lives in public places: a research based critique of residential life in local authority old people's homes.

Independent review of residential care for the elderly.

Goal planning with elderly people: making plans to meet individual needs: a manual of instruction.

Articles
Behavioural management in nursing and residential homes: a randomised controlled trial