Behavioral Symptoms Of Dementia Research Articles

Managing behavioural symptoms of dementia in Latinos

Managing behavioural symptoms of dementia in Latinos

The Role of Caregivers’ Sleep Problems in the Association between Behavioral Symptoms of Dementia and Caregiving Depression and Anxiety

ABSTRACT Objectives Behavioral problems in people with dementia are a source of depression and anxiety for caregivers, who experience high levels of sleep problems. The present study aims to explore the role of sleep problems on the relationship between behavioral problems associated with dementias – considering its different dimensions – and family caregivers’ depressive and anxious symptoms. Method 264 family caregivers participated in the study. Through face-to-face interviews, sociodemographic and health variables, caregivers’ depressive and anxious symptoms were measured, as well as their sleep problems. Data related to people with dementia symptoms and their level of independence in daily life activities were also collected. Data analysis consisted of simple mediational models using the PROCESS method for SPSS. Results the test for the indirect effect of disruptive behaviors on depression through sleep problems was statistically significant, as it was for disruptive behaviors on anxiety through sleep problems. The effect of sleep problems in the association between depressive and memory problems in the person with dementia, and caregivers’ depression and anxiety were not statistically significant. Conclusions Sleep problems are significantly and positively associated with care-recipients’ disruptive behaviors, but not with depressive and memory problems. The indirect effect of disruptive behaviors on caregivers’ mood through sleep problems suggests that disruptive behaviors seem to play an important role for understanding caregivers’ sleep problems.

Evidence on the New Drug Lumateperone (ITI-007) for Psychiatric and Neurological Disorders.

Lumateperone (ITI-007) is a tosylate salt with binding affinities to receptors implicated in the therapeutic actions of antipsychotic medications, including the serotonin 5HT2A receptors, dopamine D2 and D1 receptors and the serotonin transporter. It has a unique mechanism of action because it simultaneously modulates serotonin, dopamine, and glutamate neurotransmission, implicated in serious mental illness. It can be considered a multi-target-directed ligand and a multifunctional modulator of serotoninergic system with possible precognitive, antipsychotic, antidepressant and anxiolytic properties. Lumateperone has been investigated as a novel agent for the treatment of schizophrenia, but it represents a new potential option for other psychiatric and neurological diseases, such as behavioural symptoms of dementia or Alzheimer's disease, sleep disturbances, bipolar depression. Besides, it has demonstrated a favourable safety profile without significant extrapyramidal side effects, hyperprolactinemia or changes in cardiometabolic or endocrine factors versus placebo. Additional studies are warranted to confirm and examine the benefit of lumateperone and possible therapeutic targets. This paper is a comprehensive and thorough summary of the most important findings and potential future role of this particular compound in personalized treatments.

Monitoring behavioral symptoms of dementia using activity trackers.

Tertiary disease prevention for dementia focuses on improving the quality of life of the patient. The quality of life of people with dementia (PwD) and their caregivers is hampered by the presence of behavioral and psychological symptoms of dementia (BPSD), such as anxiety and depression. Non-pharmacological interventions have proved useful in dealing with these symptoms. However, while most PwD exhibit BPSD, their manifestation (in frequency, intensity and type) varies widely among patients, thus the need to personalize the intervention and its assessment. Traditionally, instruments to measure behavioral symptoms of dementia, such as NPI-NH and CMAI, are used to evaluate these interventions. We propose the use of activity trackers as a complement to monitor behavioral symptoms in dementia research. To illustrate this approach we describe a nine week Cognitive Stimulation Therapy conducted with the assistance of a social robot, in which the ten participants wore an activity tracker. We describe how data gathered from these wearables complements the assessment of traditional behavior assessment instruments with the advantage that this assessment can be conducted continuously and thus be used to tailor the intervention to each PwD.

Importance of Distinguishing Reactive and Proactive Aggression in Dementia Care

Aggressive behavior is one of the most disturbing symptoms of Alzheimer disease and other progressive neurodegenerative dementias. Development of strategies for management of aggressive behaviors in people with dementia is hindered by a lack of recognition that aggression is not a uniform behavioral construct. It is possible to distinguish 2 types of aggression: reactive or impulsive aggression and proactive or premeditated aggression. Research concerning aggressive behaviors in people with dementia is hindered by scales describing behavioral symptoms of dementia which do not distinguish between reactive and proactive aggressions because they do not consider the factors leading to these behaviors. Reactive aggression is caused by lack of understanding, leading to rejection of care, while proactive aggression could be caused by a psychopathic personality, hallucinations or delusions, and other determinants. It is difficult to underestimate the importance of distinguishing reactive and proactive aggressions in people with dementia because there are different strategies that can be used for management of these behaviors. For reactive aggression, delayed treatment, distraction, improved communication, and change in treatment strategy is useful, while antipsychotic medication may be needed for treatment of proactive aggression. Dementia is increasing the risk of both types of aggressions and antidepressant treatment can be helpful. Most importantly, persons exhibiting reactive aggression should not be labeled "aggressors" because this behavior could be caused by unmet persons' needs, pain and poor communication with care providers.

A review of measures of three common dementia-related behaviors: Rejection of care, aggression, and agitation

BackgroundClustering of behavioral symptoms in dementia is common in dementia scales. However, lack of distinction may have negative treatment implications when a treatment response differs depending on classification of behaviors. Historically, rejection of care, aggression, and agitation have been lumped together. Yet, several studies have indicated these may be conceptually different behaviors. ObjectiveTo examine how rejection of care, aggression, and agitation are described and operationalized in existing measures of dementia-related behaviors. MethodWe identified instruments developed to measure behavioral symptoms of dementia from two existing systematic reviews. Additionally, we conducted a literature review of peer-reviewed articles published from 1980 to 2017 to identify measures that were not captured in the two previous reviews. Results43 instruments developed to measure behavioral symptoms of dementia were examined. Of these, 25 (58.1%) included items related to rejection of care; 32 (74.4%) included items related to aggression; and 35 (81.4%) included agitation items. Descriptions of these behaviors were highly variable across the instruments. ConclusionsThe review demonstrated that rejection, aggression, and agitation are measured in most scales, yet their operationalization is highly variable, and they are not typically distinguished from each other. Future efforts should be directed at developing uniform terminology to describe dementia-related behaviors while distinguishing rejection of care, aggression, and agitation in dementia scales.

EVIDENCE FOR ELECTROCONVULSIVE THERAPY (ECT) IN THE TREATMENT OF INTRACTABLE BEHAVIORAL SYMPTOMS OF DEMENTIA (BPSD): A SYSTEMATIC REVIEW

Introduction Affecting 5.8?million individuals in the U.S. alone, the impact of Alzheimer's disease (AD) is several-fold; it increases patient morbidity and mortality, contributes to caregiver burden, increases public health burden, and comes at a staggering combined cost of over half a trillion dollars per year in health care and unpaid caregiving. Unfortunately, the behavioral symptoms of dementia (BPSD) such as agitation and aggression that largely contribute to the morbidity and burden of the disease remain neglected in the sphere of research. As the number of patients impacted by this disease rises to a predicted 13.8?million by 2050, the need for novel interventions to mitigate these BPSD contributing to the AD epidemic remains unmet. Current non-pharmacological interventions require substantial time to take effect and do not address the most severe, treatment refractory cases of BPSD. Pharmacological interventions, on the other hand, most commonly antipsychotics, have limited efficacy and are linked to substantial risks that elevate patient mortality. The limitations of these existing interventions have prompted the search for faster, safer, and more effective methods of managing BPSD in the AD population. In the past few decades, there has been growing evidence to support electroconvulsive therapy (ECT) as a safe and effective treatment to mitigate agitation in AD patients who are refractory to traditional interventions. This poster reports the results from a systematic review of the current evidence for ECT as an intervention for the mitigation of intractable BPSD in AD patients. Methods The authors conducted a literature search on Google Scholar, Medline, PubMed, and PsychInfo of the following search terms: “ECT aggression dementia,” “ECT Behavior and Psychological Symptoms of Dementia,” and “ECT BPSD.” The term “dementia” is also interchanged with “Major Neurocognitive Disorder.” The timeline for these searches was restricted to the past 30?years, allowing a list of publications between 1989-2019 to populate. Papers with only abstracts available were excluded, as were any duplicates between the searches. Results The authors reviewed 17 papers with a total (N) of 181 patients diagnosed with dementia and exhibiting severe agitation and aggression. These patients received various types of electroconvulsive therapy including: brief pulse (>0.5 msec) bitemporal (BP-BT), brief pulse right unilateral (BP-RUL) and ultrabrief pulse ( Conclusions This review of the current evidence for ECT in the treatment of severe agitation and aggression in AD, increasingly apparent is the large body of evidence for the efficacy of ECT for this indication. This review has brought to attention, however, the lack of safety data to accompany these findings on efficacy. As future prospective studies are developed to address this area of research with more robust parameters and objective scales, the studies reviewed thus far indicate a favorable risk/benefit ratio for the use of ECT in managing treatment refractory BPSD in patients with AD. This research was funded by: The National Institute of Aging (NIA 1 R01 AG061100-01)

INTEGRATING NON-PHARMACOLOGICAL AND PHARMACOLOGICAL INTERVENTIONS IN THE TREATMENT OF BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA

Non-pharmacological interventions (NI) are accepted as the first line treatment to reduce the severity and frequency of behavioral symptoms of dementia (BPSD). However, there is a marked paucity of evidenced-based NI for BPSD, leading psychiatric providers to rely too heavily on the second-line treatment for BPSD; pharmacological interventions (PI). This clinically focused presentation will demonstrate a comprehensive approach for psychiatric providers to educate family and caregivers on NI aimed to reduce the severity and frequency of BPSD, as well as integrate this teaching material with PI psycho-education. Types of NI for BPSD include sensory stimulation interventions, cognitive/emotion-oriented interventions, behavior management techniques as well as exercise and pet therapy, with music therapy and behavioral management having the most evidence for reducing BPSD. There are multiple barriers to determining evidenced based NI, which has led to geriatric psychiatry expert consensus treatment guidelines for BPSD, namely the DICE approach. The evidenced based dementia care training program STAR (Staff Training in Assisted living Residences) has demonstrated significant reduction in BPSD in dementia patients residing in the assisted living setting. Key components of this behavior management approach can be applied by psychiatric providers to family and caregiver education in the clinic and long-term care setting. Published qualitative data on barriers to implementation of dementia psycho-education have been identified, and practical strategies can counter these, including teaching providers to quickly assess family/caregiver education needs, modeling communication skills, implementing pleasant event schedules for patients to reduce BPSD, and learning how to code/bill for time spent not involving face to face time with patients. These strategies can be integrated with already published treatment algorithms for PI for BPSD, though it requires psychiatric providers to effectively educate caregivers and family members on realistic expectations and safety risks associated with PI for BPSD. Psychiatric providers can then utilize this integrated approach in their consultative role with primary care and long-term care providers. Further investigation into the effectiveness of this integrated BPSD approach is needed as well as a concerted effort to systematize the delivery of psycho-education into dementia care.

SENSORY INTERVENTIONS FOR OUTLIERS AT-RISK OF FALLS AND RESTRAINTS ON GERIATRIC PSYCHIATRY INPATIENT UNIT

Introduction Non-violent restraints are used in hospitals to address unsafe behavior in confused patients who are unable to follow redirection but are not aggressive toward self or others. On a geriatric psychiatry unit, one of the most common indications is to prevent falls. Approximately 7% of hospitalized patients will fall with up to nearly 30% of falls resulting in injury.(1) Risk factors for falls, such as cognitive impairment, agitation(2) and psychotropic medication, are very common on geriatric psychiatry inpatient units. However, data indicate that restraints may actually be associated with more falls due to deconditioning and other negative outcomes, including worsened agitation, decreased cognitive performance, walking dependence, increased difficulty with activities of daily living, pressure ulcers, and contractures.(3) Internal data from the geriatric unit at Western Psychiatric Hospital (WPH) in 2016 show that a small number of very high risk patients account for the majority of non-violent restraint. Most were patients with behavioral disturbance of dementia, including agitation, wandering and impulsivity. Often these behaviors may be driven by an unmet need, such as pain, boredom or lack of appropriate sensory stimuli.(4) Non-pharmacologic interventions such as sensory stimulation and individualized behavior plans have shown benefit in behavioral symptoms of dementia.(4,5) Aim: Our primary outcome was to reduce restraints without increasing falls with secondary outcome of decreased staff injury. Methods Setting: Integrated Health and Aging Program (IHAP), Western Psychiatric Hospital, a 40 bed geriatric psychiatric inpatient unit.Population: Approximately 35% Major Neurocognitive and 65% primary psychiatric diagnosesData collection: Number of falls and restraints per week and number of staff injuries per month were collected for an 11-month pre-intervention period beginning January 2016 and an 11-month intervention period. Intervention: Three part plan to decrease use of restraints for fall prevention, using behavioral interventions targeting patients “at-risk” for falls and restraintsPart 1: Identify “at risk” patients at admission using an initial RN screening assessment, or at any point during hospitalization by the treatment team or milieu staff.Part 2: Universal “at-risk” interventions checklist implemented by milieu staff for any patient identified as “at-risk”Part 3: Individualized behavior plan created by program director based on information collected by milieu staff in Part 2. Results Our primary outcome, restraints per week, decreased from 11.3 to 4.61 (p = 0.009) after the intervention began. The number of falls was unchanged with a mean of 6 per month before the intervention and 6.5 after (p = 0.45). Staff injuries per month decreased from 4.6 to 2.1 (p = 0.007). Conclusions The intervention successfully decreased use of nonviolent restraint without increasing falls. This benefit was sustained over at least 11 months, making it unlikely that increased observation, or the Hawthorne effect, was solely responsible. Factors that likely contributed include the successful identification of “at-risk” patients and early intervention. The behavioral interventions focused on sensory stimulation, assessment of unmet needs and individualized behavior plans which have been shown to be effective non-pharmacological interventions for behavioral disturbance of dementia. As restraint use decreased so did staff injury, demonstrating that decreased restraints benefits staff as well as patients. This likely contributed to helping create a culture change around the use of restraints ensuring that the benefits of this intervention persist. Developing an intervention targeting a very high risk population allowed us to decrease our overall restraint use. This study helped us successfully advocate for a behavioral health counselor for the unit to focus on further implementation of sensory interventions and behavior plans for patients with major neurocognitive disorder. This research was funded by: UPMC Department of Psychiatry Clinical Values Grant

BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA: UPDATE ON TREATMENTS, MECHANISMS AND MANAGEMENT IN THE CLINIC AND COMMUNITY

Behavioral and Psychological Symptoms of Dementia (BPSD) are common and challenging, with no consistently effective pharmacological or non-pharmacological treatments available. Among psychotropics, atypical antipsychotics have the strongest evidence, but adverse effects and safety concerns often outweigh benefit. SSRIs are often better tolerated, and the strongest evidence is for citalopram, but QTc prolongation is a limiting factor. Evidence for mood stabilizers is weak. Some evidence supports the use of dronabinol, prazosin, and dextromethorphan/quinidine. Pimvanserin is FDA approved for psychosis in Parkinson's disease. Options for psychosis in Dementia with Lewy bodies include cholinesterase inhibitor, quetiapine, and clozapine. Some promising results have been reported with ECT for agitation and aggression in dementia. An algorithm approach for BPSD in Alzheimer's disease (AD) and mixed dementia has been used on several inpatient units in Canada. Insights into possible biological mechanisms of BPSD throughout the spectrum of AD severity may be useful for treatment development. Areas with the best evidence include depression, anxiety and apathy in preclinical and prodromal AD. BPSD are associated with a mix of “core” mechanisms and “non-core” mechanisms of AD and may be associated with the earliest stages of AD pathology, but data remains relatively sparse. Other factors contributing to BPSD include physical and social conditions, as well as the dynamic between caregivers and persons with dementia. The MIND at Home multidisciplinary intervention is designed to support persons with dementia and their caregivers at home. Features include: completing an in home patient and caregiver-centered dementia-related needs assessment, building an evidence based care plan around patient and caregiver-specific needs, a Memory Care Coordinator (MCC) providing dementia education, support and guidance to help the dyad prioritize and follow through on care plan recommendations, and a multidisciplinary clinical team supporting the MCC, with regular team meetings, with telephone and video visit access to other team members from patients’ homes. Prior studies demonstrate that dementia care co-management models contribute to better health-related quality of life, fewer behavioral symptoms of dementia, less severe functional and cognitive symptoms, reduce stress and depression in caregivers and lead to reduced utilization of acute care services. Imperative and opportunity exist for implementing an evidence-based model of integrated dementia care across a health care system that places an emphasis on quality and reducing health care costs. Partners HealthCare, a large and diverse health care system, is in the process developing and launching such a model.

REJECTION OF CARE, AGGRESSION, AND AGITATION IN PERSONS WITH DEMENTIA: A SYSTEMATIC REVIEW OF DEFINITIONS USED IN BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA MEASURES

Introduction Objective: To examine how rejection of care, aggression, and agitation are described and operationalized in existing measures of dementia-related behaviors with a particular focus on whether these behaviors are conceptualized as separate phenomena in rating scales. Methods Methods: We identified instruments developed to measure behavioral symptoms of dementia from two systematic reviews. Additionally, we conducted a systematic review of English-language peer-reviewed articles published from 1980 to 2017 to update the previous list of the instruments and identify additional measures that were not captured in previous reviews. Results Results: 43 instruments (23 general behavior measures, 20 symptom-specific measures) developed to measure behavioral symptoms of dementia were examined. Of these, 25 (58.1%) included items related to rejection of care; 32 (74.4%) included items related to aggression; and 35 (81.4%) included agitation items. Descriptions and definitions of these behaviors were highly variable across the instruments. 13 of 23 general measures and 3 of 20 symptom specific measures included items measuring all three behaviors while the rest of the instruments included items measuring only one or two behaviors of our interest. Conclusions Conclusions: The review demonstrated that rejection, aggression, and agitation are measured in most scales, yet their operationalization is highly variable, and they are often not distinguished from each other. Researchers and clinicians need to consider each symptom in its own right and revise existing instruments to address possible misnomers to improve measurement of dementia behaviors. This research was funded by: None

CAREGIVER-RELATED FACTORS ASSOCIATED WITH THE DESIRE TO INSTITUTIONALIZE CARE RECIPIENTS WITH DEMENTIA

Introduction Institutionalization of individuals with dementia within the first five years of diagnosis occurs at a rate of 10% per year. However, surveys show that most older adults prefer to age in place in the community. Research in the past two decades indicates numerous variables are associated with increased risk of institutionalization, including both sociodemographic factors (e.g., caregiver employment, financial resources, and older care recipient age), as well as psychosocial and care recipient factors (e.g., care recipient disability level and problem behaviors). Care recipient (CR) characteristics associated with greater risk for institutionalization include increased dependence in activities of daily living, severity of cognitive impairment, and frequency and severity of behavioral symptoms of dementia. Previously investigated caregiver (CG) characteristics, such as physical well-being and self-care behaviors, CG burden and social support, may also contribute to the risk of institutionalization. However, these identified CG factors have not yet been routinely assessed in clinical practice. Additionally, CGs are at a greater risk for poor health, depression, and use of psychotropic drugs and health services. Our aim was to examine the relationship between CG-related factors (e.g., depressive symptomatology, CG burden, perceived health, and social support) and the desire to institutionalize the CR among a real-world community sample of CGs of older adults with dementia. We hypothesized that specific CG domains, including greater perceived health and social support, would decrease the desire to institutionalize the CR. Methods The sample included 334 caregivers (CGs) of older (aged 65+), community-dwelling, low-income care recipients (CRs) prescribed a cholinesterase inhibitor or memantine who met criteria for dementia. CRs were identified from a sample of older adults receiving pharmaceutical assistance from the Pennsylvania Department of Aging's Pharmaceutical Assistance Contract for the Elderly (PACE) program. All eligible CGs who gave verbal consent to participate were enrolled in the Caregiver Resources, Education, and SupporT (CREST) program, a state-sponsored, University-delivered service, with assessment and support provided by behavioral health clinicians (nurses, social worker and psychologist) via telephone. Upon commencing the program, CGs completed a comprehensive assessment that captured sociodemographics and CR's clinical characteristics (including the Revised Memory and Behavior Problems Checklist (RMBPC) for dementia-related symptoms, frequency and severity), the REACH Risk Appraisal Measure (with sub-scales for CG depressive symptoms, social support, and perceived caregiving strain), the Zarit Burden Interview (for caregiving-related burden, perceived general health), and the Desire to Institutionalize Scale (e.g., ever considered placing CR in a nursing home, taken steps to place CR, etc.). Results CGs were on average 65.6?years old (SD=12.1) and primarily female (73.1%) and non-Hispanic White (79.6%). Over half (58.4%) of CGs were adult children of the CRs and providing full-time care (60.5%). Bivariate analyses revealed that greater desire to institutionalize was positively correlated with the following variables: CR's total ADL/IADL difficulty and frequency of dementia-related behavioral symptoms, younger CG age, caregiving burden, caregiving strain, less social support, and being a non-spousal CG. An adjusted regression model revealed that only greater ADL/IADL difficulty (p=0.02), caregiving strain (p=0.003), and social support (p=0.01) were uniquely and significantly associated with CGs’ desire to institutionalize, after controlling for all other variables. Conclusions Findings from this real-world, clinical, community-based sample identified three variables that independently predict increased CG desire to institutionalize the CR. The findings point to the potential value of systematically addressing CG-level factors and incorporating CG assessments into routine clinical care for patients with dementia. Routine CG assessment may increase opportunities for families, health care providers, health systems and community agencies to identify cases in which providing increased ADL/IADL support, reducing caregiver strain, or increasing social supports might lead to reductions in CGs' desire to institutionalize, and increase the chances for care recipients to age in place. This research was funded by: Commonwealth of Pennsylvania, Department of Aging, PACE Program, PACE/PACENET.

Radio Signal Sensing and Signal Processing to Monitor Behavioral Symptoms in Dementia: A Case Study

ObjectivesAlzheimer's Disease (AD)-related behavioral symptoms (i.e. agitation and/or pacing) develop in nearly 90% of AD patients. In this N = 1 study, we provide proof-of-concept of detecting changes in movement patterns that may reflect underlying behavioral symptoms using a highly novel radio sensor and identifying environmental triggers. MethodsThe Emerald device is a Wi-Fi-like box without on-body sensors, which emits and processes radio-waves to infer patient movement, spatial location and activity. It was installed for 70 days in the room of patient ‘E’, exhibiting agitated behaviors. ResultsDaily motion episode aggregation revealed motor activity fluctuation throughout the data collection period which was associated with potential socio-environmental triggers. We did not detect any adverse events attributable to the use of the device. ConclusionThis N-of-1 study suggests the Emerald device is feasible to use and can potentially yield actionable data regarding behavioral symptom management. No active or potential device risks were encountered.

The Use of Opioids and Antipsychotics in Elderly with Dementia - Have Opioids Replaced Antipsychotics in Treating Behavioral Symptoms in Dementia?

Background:Opioids are used with increasing frequency. Elderly with dementia are prescribed opioids more frequent than elderly without. One possible explanation is that opioids may be used not only to treat pain but also behavioral symptoms.Objective:To test the hypothesis that strong opioid use, especially transdermal formulations, had increased, especially in elderly with dementia, in parallel with a decrease in antipsychotic use.Methods:Population-based cross-sectional study conducted using nationwide Danish registers with data on Denmark’s entire elderly population age ≥65 (2000: n = 802,106; 2015: n = 1,056,476). The registers were used to identify elderly with and without dementia and filled prescriptions for opioids and antipsychotics. Annual prevalence of opioid and antipsychotic use from 2000–2015 was calculated.Results:Prevalence of opioid use increased by 35% (24.2 to 32.5%) among elderly with dementia and by 13% among elderly without (14.9 to 16.8%) from 2000–2015. The disproportionate increase in opioid use among elderly with dementia was mainly driven by an increase in strong opioids (dementia: 11.7 to 23.1%; without dementia: 5.9 to 7.4%). Use of antipsychotics decreased during the same period (dementia: 31.3 to 19.3%; no dementia: 4.5 to 2.7%).Conclusion:From 2000–2015, use of opioids among the elderly increased with a disproportionately higher increase among elderly with dementia. The parallel decrease in the use of antipsychotics may suggest that opioids to some extent have replaced antipsychotics in managing behavioral symptoms, despite safety concerns and lack of evidence for effect of opioids. Future research should focus on potential risks associated with increased opioid use.

Addressing Behavioral Symptoms of Dementia Through STAR-VA Implementation: Do Outcomes Vary by Behavior Type?

The STAR-VA program in Veterans Health Administration Community Living Centers (CLCs, nursing home settings) trains teams to implement a psychosocial intervention with residents with behavioral symptoms of dementia (BSD). Across 71 CLCs, 302 residents selected as training cases had target behaviors categorized into one of 5 types: physically aggressive (PA), physically nonaggressive, verbally aggressive, verbally nonaggressive, and behavior deficit (BD). Across all groups, there were significant declines in team-rated behavior frequency (36%) and severity (44%), agitation (10%), distress behaviors (42%), depression (17%), and anxiety (20%). The magnitude of changes varied across behavior category. For example, those with a PA target behavior experienced a greater percentage decline in agitation and distress behavior scores, and those with a BD target behavior experienced a greater percentage decline in depressive and anxiety symptoms. STAR-VA, a multicomponent intervention, is generally effective across various types of behavioral symptoms associated with dementia.

QUALITY IMPROVEMENT IN DEMENTIA CARE: EFFECTIVENESS OF IMPLEMENTING STAR-VA IN A VA COMMUNITY LIVING CENTER

Staff Training in Assisted Living Residences adapted for Veterans Affairs (STAR-VA) is an evidence-based, interdisciplinary behavioral intervention to manage challenging Behavioral Symptoms of Dementia (BSD) at VA Community Living Centers (CLCs). Components of STAR-VA included creating realistic expectations for individuals with dementia, effective communication, using a behavioral problem-solving approach, and increasing resident-centered pleasant events. STAR-VA was implemented at VA Western New York CLC to help staff manage Veteran BSD. The purpose of the study was to examine the effectiveness of STAR-VA implementation in 17 CLC Veterans with Dementia who demonstrated BSD distressing to themselves, other Veterans and/or staff and documented in 2017-2018. STAR-VA was facilitated by the behavioral coordinator and nurse champion in partnership with the CLC behavior team during weekly rounds and as needed modeling and debriefing. The team included the medical provider, recreation therapist, social worker, and all levels of nursing. On average, the intervention involved four assessments over 75 days. Outcome measures at baseline and post-intervention included assessments of target behavior frequency and severity, direct care tracking of behaviors, and the Minimum Data Set distress behavior indicator. Compared to baseline scores, clinically meaningful reduction was documented using team assessment and direct care ratings of BSD frequency and severity, and overall inappropriate utilization of antipsychotic medication. CLC clinical staff tailored implementation of STAR-VA to be feasible and effective. Ongoing evaluation of STAR-VA implementation using routine measures promotes measurement based care, providing feedback to the team to improve care quality.

AN MDS 3.0 BEHAVIORAL INDICATOR: RELIABILITY AND VALIDITY WHEN MEASURING BEHAVIOR SYMPTOMS OF DEMENTIA IN CLCS

Persons with dementia frequently demonstrate behavior symptoms of dementia (BSD), associated with poorer outcomes. A measure of BSD was created for routine use in VA Community Living Centers (CLCs). Reliability and validity of Minimum Data Set (MDS 3.0) behavior items was established using exploratory factor analysis and a multitrait, multimethod correlation matrix. 385 CLC residents with BSD were assessed using validated measures of BSD, depression, and anxiety, and team ratings of the frequency and severity of target behaviors identified for intervention. Factor analysis on MDS items closest to baseline resulted in two stable factors. MDS behavior factors related to validated clinical measures in predicted ways at baseline and post-intervention. MDS distress behavior factor sensitivity to change was evaluated by using change score correlations with validated clinical measures. The MDS distress behavior factor can be used routinely, evaluate the impact of intervention effectiveness, and provide quality improvement feedback.

SUSTAINING STAR-VA: EVALUATING SYSTEMIC OUTCOMES AND TEAM STRATEGIES FOR MANAGING BEHAVIOR SYMPTOMS OF DEMENTIA

The Veterans Health Administration (VHA) has invested in the implementation and evaluation of STAR-VA, a Veteran-centered, interprofessional intervention for managing behavioral symptoms of dementia (BSD), with 86 Community Living Center (CLC nursing home) teams between 2013 and 2018. Results of a VHA Quality Enhancement Research Initiative (QUERI) partnered evaluation project are presented, including a multi-site interprofessional network created to collaborate on evaluation of the longitudinal impact of STAR-VA on CLC Veteran- and site-level outcomes, and to determine factors associated with sustained implementation and positive outcomes. The development and validation of a Minimum Data Set quality indicator of behavior symptoms of dementia (BSD) is presented. Characteristics of STAR-VA trained and untrained CLCs are presented, along with facilitators and barriers to sustained program implementation. Findings support the effectiveness of implementation of STAR-VA on decreased use of psychotropic medication. Qualitative outcomes demonstrate importance of having the appropriate staff, positive team relationships, supportive usual routines, and culture as critical for STAR-VA sustainability efforts. Results emphasize the importance of using a valid, routine measure of BSD to provide feedback to CLC teams, and to develop a sustainability intervention focused on addressing reported barriers to program sustainability through interprofessional networks. Both qualitative and quantitative outcomes will inform development and recommendations for an implementation and evaluation strategy for an outcome-driven, tailored intervention to support CLC teams in sustaining STAR-VA and to improve poor-performer and maintain high-performer outcomes. The potential benefit of our findings for other interprofessional behavioral nursing home interventions will be discussed.

EVALUATING THE IMPACT OF STAR-VA ON VETERANS’ PSYCHOTROPIC MEDICATION USE IN CLCS

The impact of STAR-VA on psychotropic drug use among residents with behavioral symptoms of dementia was evaluated through a difference-in-differences framework. STAR-VA residents enrolled 2013-2017 were evaluated longitudinally pre-post intervention. The primary outcome was the number of as needed administrations with an indication of ‘anxiety’ or ‘agitation’. The analytical cohort included 214 training cases and 1,870 controls from untrained sites meeting eligibility criteria. STAR-VA cases were less white (48% vs. 54%), less black (11% vs. 14%), and had significantly longer median length of stay (830 vs. 261 days), respectively. STAR-VA cases had on average 3.5 as needed doses/month of psychotropic medication before the intervention and 1.7 after, controls averaged 1.8 doses/month. After adjustment for person-time-fixed effects, enrollment was associated with 55% (95% CI:30, 68) reduction or an average 0.8 as needed psychotropic doses/month. Findings demonstrate effectiveness in decreasing as-needed psychotropic drug use among CLC residents, supporting continued implementation of STAR-VA.

CAREGIVER PREFERRED STRUCTURE FOR A TELEHEALTH-BASED INTERVENTION ONE-TO-ONE VERSUS GROUP

Caring for a person with Alzheimer’s disease and related dementias (ADRD) can be stressful. Support programs are available for caregivers, but distance and cost present barriers to participation. Our mixed-methods study explored consumer acceptability and preliminary efficacy of a telehealth-based caregiver intervention, Tele-STAR. Caregivers in Tele-STAR met one-to-one with a consultant over eight weeks, via video conferencing, to address behavioral symptoms of dementia. We measured the effect of the intervention on caregiver reactivity to behavioral symptoms. Focus groups were used to assess acceptability. The literature suggests that stressed caregivers drop out of support programs. Thus, in the focus groups we asked about preference for intervention mode (one-to-one versus group). We hypothesized that more stressed caregivers would prefer the one-to-one mode. Data were analyzed using paired t-tests for the quantitative data, and a phenomenological lens for the qualitative data. Of the thirteen enrolled caregivers, twelve completed the study. Significant improvement was found in caregiver reactivity (p=0.001). Twelve caregivers participated in focus groups, in which they reported that the intervention helpful and they valued the therapeutic relationships with the consultants. Few had difficulty with the technological interface. Most liked the one-to-one mode of the intervention, but were open to a hypothetical group-based option. However, more stressed caregivers preferred a one-to-one intervention over a group intervention (p=0.06). While one-to-one interventions tend to be preferred by caregivers, they are expensive. Our findings suggest that one-to-one telehealth-based interventions should be reserved for more stressed caregivers who need intensive support with managing behavioral symptoms of dementia.