An individualized psychosocial approach for [ldquor]treatment resistant[rdquor] behavioral symptoms of dementia among aged care residents

Abstract

This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

“…For example, in family care settings, frequent behaviours are not necessarily the most challenging for carers; 47 the carer's own characteristics (independent of dementia severity) and their sense of a declining relationship with their relative can contribute to the development or maintenance of CB. 48,49 Emotional responses to, and perception of, the behaviour vary widely, 26,50 from extreme distress to regarding the behaviour as 'no problem'. Most people are distressed by behaviours such as screaming, repetitive questions, violence or behaviour of great intensity.…”

“…Changes in behaviour or family carer or staff distress are more likely to occur in programmes that are more case or client specific, that is, education that is person centred or more explicitly links interventions to the specific environment. 60 Examples of outcomes for people with dementia living in residential care have been reductions in frequency and perceived severity of the target behaviour and general practitioner (GP) call-outs, 50 reductions in antipsychotic use, 27 reductions in agitated behaviour and increases in observed participant pleasure, 61 reductions in behaviour frequency and perceived severity, hospitalisations, antipsychotic use, and drug side effects; 26,62 and for staff, reductions in stress and short-term improvements in the perception of how challenging staff found the behaviour. 63 Systematic interventions of this type, targeting a variety of outcomes within family care settings, are less common, but they can be found, including within NHS settings in England, where they have demonstrated reductions in CB and improvements in carer mental health.…”

“…However, Bird et al 26 showed that the individualised formulaic 'case-specific' approach was no more time consuming when compared with 'usual care' practice in residential care settings, but it still required a mean of 5.5 clinical visits per case. Applying a similar approach to 'treatment-resistant cases', in care homes, Davison et al 50 required a median of 3 months per case, spread over three visits, to achieve improvements in some, but not necessarily in more complex or treatment-resistant cases. This necessitates significant time/resource investment, namely addressing the shortage of clinicians with the requisite skills to provide the necessary assessment and subsequent intervention to the large and growing number of older people with dementia and CB, and those who care for them.…”

“…The sometimes hidden 'scaffolding' 185,186 that practitioners require for the delivery of these types of interventions is implicit in most successful applications of case-specific dementia care interventions, 289 including those for CB. 26,50 Routine supervision and support from skilled professionals with relevant expertise are therefore particularly important for the management of dementia with CB at home.…”

“…97,186,303,304 They are usually algorithmic to enhance case specificity 62 and are delivered by trained practitioners who have access to knowledge and expertise from other professionals such as psychiatrists, geriatricians and experienced psychologists. 15,26,27,50,97 A trained therapist is usually required for such an intervention, 82 as a key skill in working in this area is the ability to be flexible and have the capability to alter care plans as new needs arise, meaning that the process remains iterative but the functional analytical skills remain at the core of the plan. A review of computerised clinical decision support systems suggests that these may improve practitioner performance, but to date the effects on patient outcomes are understudied or inconsistent.…”