Cohen-Mansfield Agitation Inventory Scores Research Articles

Antipsychotic Prescribing and Falls Risk in Nursing Home Residents with Dementia

Abstract Background Falls are a common syndrome in older adults leading to adverse outcomes including functional decline, activity restriction, injury and death. They can still occur in residential care. We examined prescribing of medications included in STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) (1) in nursing home residents with dementia. Methods A point prevalence audit was conducted in a dementia-specific nursing home. Data were collected from the electronic healthcare record on demographics, dementia severity, and number of falls in the preceding 12 months. The number and class of regular medications were recorded. Non-cognitive symptoms of dementia were quantified using the Cohen Mansfield Agitation Inventory (CMAI). Results Seventy-four residents were included with mean age 82 years, 59(70%) female. The average Mini Mental State Examination (MMSE) was 5/30 and 80% had severe dementia. The average CMAI score was 50. The mean number of falls was 3 (range 0-14). Regular prescribing of specific STOPPFall medications was as follows: antipsychotics 42/74 (57%), benzodiazepines 8/74 (11%), opioids 13/74 (18%), antidepressants 44/74 (59%), antiepileptics 11.74 (15%), diuretics 12/74 (16%). Prescription of a regular antipsychotic was associated with one or more falls (OR 3.19, p = 0.029). There was no significant difference in falls with the other medications studied. The number of falls increased with higher agitation scores. Conclusion Antipsychotics increased the risk of falls in a nursing home setting. Fallers had higher rates of agitation, perhaps explaining the increased usage of antipsychotics. Medications should be reviewed on a regular basis and deprescribing considered where appropriate. Reference 1. Seppala LJ, Petrovic M, Ryg J, Bahat G, Topinkova E, Szczerbińska K, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drgs. Age and Ageing. 2020;50(4):1189-99.

Nursing strategies for enhancing calm in older Arabs with dementia: integrating Snoezelen methods, aromatherapy, and personal items to reduce agitation

BackgroundAgitation significantly impacts Arab elders with dementia. Multisensory stimulation, such as Snoezelen, shows promise but lacks exploration in Arab contexts. ObjectiveEvaluate a culturally adapted multisensory intervention—combining Snoezelen, aromatherapy, and personal items—on agitation in Arab elders with dementia. MethodsA quasi-experimental design assessed 31 patients receiving the intervention against 31 controls. Agitation, quality of life, and neuropsychiatric symptoms were measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI). ResultsThe intervention group exhibited notable reductions in CMAI scores for aggression and agitation behaviors (p < 0.001) and improvements in quality of life and NPI scores for agitation/aggression and depression/dysphoria (p < 0.001). ConclusionThis culturally tailored multisensory approach effectively reduced agitation and improved well-being in Arab dementia patients. The findings advocate for further research and suggest such interventions can be beneficial in culturally diverse dementia care settings. Trial registrationClinicalTrials.gov, ID NCT06216275

Efficacy of Aromatherapy Against Behavioral and Psychological Disturbances in People With Dementia: A Meta-Analysis of Randomized Controlled Trials

ObjectivesBehavioral and psychological symptoms of dementia (BPSD) are common in people with dementia. Aromatherapy may reduce the frequency and severity of BPSD. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of aromatherapy in relieving BPSD and improving functional ability in people with dementia. DesignSystematic review and meta-analysis. Setting and ParticipantsPatients with dementia receiving aromatherapy. MethodsA literature search was conducted using PubMed, Embase, and Cochrane Library for RCTs published before March 2024 comparing aromatherapy with control treatments in patients with dementia. ResultsThere were 15 trials involving 821 patients. Overall, significant reduction in BPSD was observed after 1 month of aromatherapy treatment. Among 15 trials, 9 reported the Cohen-Mansfield Agitation Inventory (CMAI) score, and 7 evaluated the Neuropsychiatric Inventory (NPI) score. The meta-analysis showed significant improvement in CMAI score [weighted mean difference (WMD) −6.31, 95% CI −9.52 to −3.11] and NPI score (WMD −8.07, 95% CI −13.53 to −2.61) in patients receiving 3 to 4 weeks of aromatherapy compared with the control group. Four of the 15 trials reported improvement in depressive mood and 3 trials reported no significant improvement in functional ability. Conclusions and ImplicationsIn conclusion, aromatherapy is a safe and viable nonpharmacologic treatment to improve BPSD in people with dementia and its combination with massage showed higher efficacy.

Systematic literature review with meta-analysis on essential oil interventions for agitated behavior in dementia patients

Introduction Essential oil treatment has been explored as a potential alternative medicine, as these therapies can induce calming and sedative effects by acting on the neuro-limbic system and upregulating neurotransmitter synthesis. Objectives This paper aims to assess the impact of essential oil interventions on aggressive behavior in people with dementia. Methods The literature search was carried out through six databases. The outcomes of interest were the survival risk and post-treatment score of the Cohen-Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory (NPI), and Quality of Life (QoL). Quality appraisal was done using RoB 2.0, while meta-analysis was done using RevMan 5.4. This systematic review has been registered to the PROSPERO database (CRD42023476844). Results We analyzed 11 included studies with 1,418 patients. RoB 2.0 analysis resulted in eight low-risk-of-bias and three high-risk-of-bias studies. This study suggests that essential oil interventions lead to statistically significant improvements in survival risk with moderate heterogeneity [OR = 0.63 (95% CI: 0.41, 0.98, p = 0.04; I2 = 74%)]. This study also found a significant improvement in NPI scores following the use of essential oils [SMD = -2.97 (95% CI = -5.61, -0.32, p = 0.03; I2 = 98%)], but no statistically significant improvements were found in CMAI scores [SMD = 0.17 (95% CI = 0.37, 0.71, p = 0.53; I2 = 74%)]. The QoL assessment showed a trend favoring the control group after implementing essential oil treatments [SMD = 4.89 (95% CI = 1.51, 8.27, p = 0.005; I2 = 98%)]. Conclusions Essential oil is a potential approach in alleviating the agitated behavior of dementia patients considering its survival risk and some parameters, such as NPI, CMAI, and QoL score. However, more studies regarding essential oils on these parameters should be done, especially studies with specific main ingredients of the essential oil.

Short Report: Measuring the Behavioral Disturbance of Autism Spectrum Disorder by Cohen-Mansfield Agitation Inventory

Introduction: Cohen-Mansfield Agitation Inventory (CMAI) has originally been developed for the evaluation of agitation in Alzheimer’s disease. Reliable tools for measuring behavioral symptoms in autism spectrum disorder (ASD) are missing. Methods: The reproducibility of the CMAI was evaluated in 26 patients. The CMAI-questionnaire was filled for each participant by three different nurses. The measurement was repeated by the primary caregiver for 15 patients. Agreement between nurses was measured using Cohen’s weighed kappa, intraclass correlation coefficient (ICC) was used to evaluate intra-rater reliability and Cronbach’s alphas to quantify internal consistency. Results: The inter-rater reliability was found to be substantial for all items ICC 0.64 (95%CI 0.43-0.80). Cronbach’s alpha was good for the whole CMAI score (α=0.87 with 95% CI 0.82-0.91). No statistically significant differences were seen in the CMAI-scores between repeated measurements. Conclusions: The CMAI may be a reasonably reliable tool to follow-up changes in behavioral symptoms of ASD.

Effects of reminiscence therapy on cognition, agitation, and quality of life in older adults with dementia receiving long-term care.

Dementia is one of the most common neuropsychiatric conditions in older adults. Despite many older adults with dementia receiving long-term care (LTC), few studies have been conducted in Turkey on reminiscence therapy (RT) influencing neuropsychiatric symptoms and quality of life in people with dementia receiving LTC. This study aimed to investigate the effect of RT on cognition, agitation, and quality of life in older adults with dementia receiving LTC in Turkey. The study population consisted of 100 older adults living in a LTC centre in a province. The size of the research group was calculated using the power analysis method, and 54 older adults were included in the study, 27 each in the RT and control (C) groups. Data collection forms Mini-Mental State Examination (MMSE), Cohen-Mansfield Agitation Inventory (CMAI), and the Alzheimer's Disease Quality-of-Life Scale (AD-QOL) were applied to the RT and C groups before RT (T0 ), 1 week after RT (T1 ), 1 month after RT (T2 ), and 3 months after RT (T3 ) to evaluate the effectiveness of the intervention. Mean, standard deviation, ratio, percentile, Fisher's exact test, Pearson Chi-square test, Mann-Whitney U-test, and Friedman test were used in analyzing the data. Older adults in the RT and C groups were similar regarding sociodemographic characteristics, institutional care, and life models (P > 0.05). When comparing the T3 values of MMSE, CMAI, and AD-QOL total scores with the T0 values, a significant difference was observed between the groups, favouring the RT group (P < 0.001). Individual RT may benefit cognition, agitation, and quality of life of older adults with dementia residing in a LTC centre.

Effectiveness of a home-based, family caregiver–administered manual massage intervention in managing dementia symptoms and reducing caregiver stress: A randomized, controlled clinical trial

ObjectivesTo investigate the effectiveness of family caregiver–administered home-based manual massages in managing dementia symptoms and reducing caregiver stress. MethodsThirty-eight pairs of participants—patients with dementia and their family caregivers—were randomly allocated to the experimental or the control group. The caregivers underwent 3-h-long massage training. Subsequently, the patients received a 30-min-long, home-based massage from their caregivers thrice a week for 8 consecutive weeks. The Cornell Scale for Depression in Dementia (CSDD), Cohen-Mansfield Agitation Inventory (CMAI), and Perceived Stress Scale (PSS) were assessed before and after the interventions. ResultsAfter intervention, the experimental group exhibited significant improvements in CSDD and CMAI scores compared with the scores of the control group (all p < .001). Furthermore, the experimental group obtained more favorable PSS scores than did the control group (p = .013). ConclusionsFamily caregiver–administered home-based massage therapy is recommended for managing dementia symptoms and reducing caregiver stress.

Phototherapy improves cognitive function in dementia: A systematic review and meta-analysis.

This study aimed to investigate the effectiveness of phototherapy intervention on cognitive function in older adult patients with dementia. PubMed, Ovid MEDLINE, Web of Science, EMBASE, Cochrane Central Registry of Controlled Trials, PsycINFO, and Clinical Trials were searched from their inception to August 10, 2022, for randomized controlled trials involving patients with dementia who received phototherapy interventions. We used the weighted mean difference (MD) or standard weighted mean difference to generate the pooled estimates. The primary outcome was cognitive function as measured by the Mini-Mental State Examination (MMSE) score. The secondary outcomes were the behavioral and psychological symptoms of dementia (BPSDs) and sleep. This systematic review and meta-analysis was registered in PROSPERO (registration number: CRD42022343788). We included 12 randomized controlled trials comprising 766 patients with dementia (426 patients in the intervention group and 340 in the control group). Phototherapy interventions significantly improved MMSE scores (n = 3, MD 2.68, 95% confidence interval [CI]: 1.38-3.98, I2 =0%). There were no significant differences in the Cornell Scale for Depression in Dementia score, Cohen-Mansfield Agitation Inventory score (MD: -3.12, 95% CI: -8.05, 1.82, I2 =0%), Neuropsychiatric Inventory score, sleep efficiency, total sleep time, and Sleep Disorders Inventory score between the groups. Our systematic review and meta-analysis showed that phototherapy significantly improved cognitive function in patients with dementia.

Effects of rich cannabidiol oil on behavioral disturbances in patients with dementia: A placebo controlled randomized clinical trial.

BackgroundAlmost 90% of patients with dementia suffer from some type of neurobehavioral symptom, and there are no approved medications to address these symptoms.ObjectiveTo evaluate the safety and efficacy of the medical cannabis oil “Avidekel” for the reduction of behavioral disturbances among patients with dementia.Materials and methodsIn this randomized, double-blind, single-cite, placebo-controlled trial conducted in Israel (ClinicalTrials.gov: NCT03328676), patients aged at least 60, with a diagnosis of major neurocognitive disorder and associated behavioral disturbances were randomized 2:1 to receive either “Avidekel,” a broad-spectrum cannabis oil (30% cannabidiol and 1% tetrahydrocannabinol: 295 mg and 12.5 mg per ml, respectively; n = 40) or a placebo oil (n = 20) three times a day for 16 weeks. The primary outcome was a decrease, as compared to baseline, of four or more points on the Cohen-Mansfield Agitation Inventory score by week 16.ResultsFrom 60 randomized patients [mean age, 79.4 years; 36 women (60.0%)], 52 (86.7%) completed the trial (all eight patients who discontinued treatment were from the investigational group). There was a statistically significant difference in the proportion of subjects who had a Cohen-Mansfield Agitation Inventory score reduction of ≥ 4 points at week 16: 24/40 (60.0%) and 6/20 (30.0%) for investigational and control groups, respectively (χ2 = 4.80, P = 0.03). There was a statistically significant difference in the proportion of subjects who had a Cohen-Mansfield Agitation Inventory score reduction of ≥ 8 points at week 16: 20/40 (50%) and 3/20 (15%), respectively (χ2 = 6.42, P = 0.011). The ANOVA repeated measures analysis demonstrated significantly more improvement in the investigational group compared to the control group at weeks 14 and 16 (F = 3.18, P = 0.02). Treatment was mostly safe, with no significant differences in the occurrence of adverse events between the two groups.ConclusionIn this randomized controlled trial, ‘Avidekel’ oil significantly reduced agitation over placebo in patients suffering from behavioral disturbances related to dementia, with non-serious side-effects. Further research is required with a larger sample size.

Optimizing Practices, Use, Care, and Services-Antipsychotics (OPUS-AP) in Long-Term Care Centers in Quebec, Canada: A Successful Scale-Up.

To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated. Prospective, closed cohort. Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada. The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9months. OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase2. The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing.

Neuropsychiatric Symptoms in Dementia: Considering a Clinical Role for Electroencephalography.

Degenerative dementia is characterized by progressive cognitive decline and neuropsychiatric symptoms. People with Alzheimer's disease (AD), the most common cause of dementia, show synaptic loss and disruption of functional brain networks along with neuritic plaques and neurofibrillary tangles. Electroencephalography (EEG) directly reflects synaptic activity, and among patients with AD it is associated with slowing of background activity. The purpose of this study was to identify associations between neuropsychiatric symptoms and EEG in patients with dementia and to determine whether EEG parameters could be used for clinical assessment of pharmacological treatment of neuropsychiatric symptoms in dementia (NPSD) with galantamine or risperidone. Seventy-two patients with EEG recordings and a score ≥10 on the Neuropsychiatric Inventory (NPI) were included. Clinical assessments included administration of the NPI, the Mini-Mental State Examination (MMSE), and the Cohen-Mansfield Agitation Inventory (CMAI). Patients underwent EEG examinations at baseline and after 12 weeks of treatment with galantamine or risperidone. EEG frequency analysis was performed. Correlations between EEG and assessment scale scores were statistically examined, as were EEG changes from baseline to the week 12 visit and the relationship with NPI, CMAI, and MMSE scores. Significant correlations were found between NPI agitation and delta EEG frequencies at baseline and week 12. No other consistent and significant relationships were observed between NPSD and EEG at baseline, after NPSD treatment, or in the change in EEG from baseline to follow-up. The limited informative findings in this study suggest that there exists a complex relationship between NPSD and EEG; hence, it is difficult to evaluate and use EEG for clinical assessment of pharmacological NPSD treatment.

Study of mirtazapine for agitated behaviours in dementia (SYMBAD): a randomised, double-blind, placebo-controlled trial

SummaryBackgroundAgitation is common in people with dementia and negatively affects the quality of life of both people with dementia and carers. Non-drug patient-centred care is the first-line treatment, but there is a need for other treatment when this care is not effective. Current evidence is sparse on safer and effective alternatives to antipsychotics. We assessed the efficacy and safety of mirtazapine, an antidepressant prescribed for agitation in dementia.MethodsThis parallel-group, double-blind, placebo-controlled trial—the Study of Mirtazapine for Agitated Behaviours in Dementia trial (SYMBAD)—was done in 26 UK centres. Participants had probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, and a Cohen-Mansfield Agitation Inventory (CMAI) score of 45 or more. They were randomly assigned (1:1) to receive either mirtazapine (titrated to 45 mg) or placebo. The primary outcome was reduction in CMAI score at 12 weeks. This trial is registered with ClinicalTrials.gov, NCT03031184, and ISRCTN17411897.FindingsBetween Jan 26, 2017, and March 6, 2020, 204 participants were recruited and randomised. Mean CMAI scores at 12 weeks were not significantly different between participants receiving mirtazapine and participants receiving placebo (adjusted mean difference –1·74, 95% CI –7·17 to 3·69; p=0·53). The number of controls with adverse events (65 [64%] of 102 controls) was similar to that in the mirtazapine group (67 [66%] of 102 participants receiving mirtazapine). However, there were more deaths in the mirtazapine group (n=7) by week 16 than in the control group (n=1), with post-hoc analysis suggesting this difference was of marginal statistical significance (p=0·065).InterpretationThis trial found no benefit of mirtazapine compared with placebo, and we observed a potentially higher mortality with use of mirtazapine. The data from this study do not support using mirtazapine as a treatment for agitation in dementia.FundingUK National Institute for Health Research Health Technology Assessment Programme.

Vocally disruptive behaviour in nursing home residents in Ireland: a descriptive study.

Vocally disruptive behaviour (VDB) is relatively common in nursing home residents but difficult to treat. There is limited study on prevalence and treatment of VDB. We hypothesise that VDB is a result of complex interaction between patient factors and environmental contributors. Residents of nursing homes in south Dublin were the target population for this study. Inclusion criteria were that the residents were 65 years or over and exhibited VDB significant enough for consideration in the resident's care plan. Information on typology and frequency of VDB, Interventions employed and their efficacy, diagnoses, Cohen-Mansfield Agitation Inventory scores, Mini-Mental State Examination scores, and Barthel Index scores were obtained. Eight percent of nursing home residents were reported to display VDB, most commonly screaming (in 39.4% of vocally disruptive residents). VDB was associated with physical agitation and dementia; together, these two factors accounted for almost two-thirds of the variation in VDB between residents. One-to-one attention, engaging in conversation, redirecting behaviour, and use of psychotropic medication were reported by nurses as the most useful interventions. Analgesics were the medications most commonly used (65.7%) followed by quetiapine (62.9%), and these were reportedly effective in 82.6% and 77.2% of residents respectively. VDB is common, challenging, and difficult to manage. The study of VDB is limited by a variety of factors that both contribute to this behaviour and make its treatment challenging. Issues relating to capacity and ethics make it difficult to conduct randomised controlled trials of treatments for VDB in the population affected.

Effect of acupressure on agitation in the elderly with dementia who receive institutional care: A pilot study.

This pilot study was carried out to determine the effect of acupressure on agitation in the elderly with dementia who receive institutional care. The study sample consisted of 38 elderly individuals (acupressure group [AG] = 19, usual-care group = 19). Acupressure application was performed on four points. The results were measured at the beginning (T0 ), the week after acupressure was completed (T1 ), and 2 weeks after acupressure was completed (T2 ). The change in the total Cohen-Mansfield Agitation Inventory score across the groups at T1 , T2 , and T3 was statistically significant in favor of AG. The acupressure used in this study can be used for managing agitation in the elderly with dementia.

Long-Term, All-Day Exposure to Circadian-Effective Light Improves Sleep, Mood, and Behavior in Persons with Dementia.

Background:Persons with Alzheimer’s disease and related dementias (ADRD) frequently experience sleep–wake (circadian) cycle disturbances that lead them to remain awake at night, causing stress and fatigue for families and caregivers. Light therapy shows promise as a nonpharmacological treatment for regulating sleep in this population.Objective:We investigated the long-term impact of a circadian-effective lighting intervention on sleep, mood, and behavior problems in persons with ADRD.Methods:This 25-week clinical trial administered an all-day lighting intervention to 47 patients with ADRD in 9 senior-care facilities, employing wrist-worn actigraphy measures and standardized measures of sleep quality, mood, and behavior.Results:The intervention significantly improved Pittsburgh Sleep Quality Index scores, from an estimated mean±SEM of 11.89±0.53 at baseline to 5.36±0.63 at the end of the intervention. Additional improvements were noted for sleep efficiency data from actigraph measurements. The intervention significantly reduced Cornell Scale for Depression in Dementia scores (mean±SEM of 11.36±0.74 at baseline and 4.18±0.88 at the end of the intervention) and Cohen-Mansfield Agitation Inventory scores (mean±SEM of 47.10±1.98 at baseline and 35.33±2.23 at the end of the intervention).Conclusion:A regular circadian-effective daytime lighting intervention can improve sleep at night and reduce depression and agitation in patients with dementia living in controlled environments. More importantly, the positive effects of the tailored lighting intervention on these outcomes appear to be cumulative over time.

Effectiveness of Dementia Care Mapping™ to reduce agitation in care home residents with dementia: an open-cohort cluster randomised controlled trial

Objectives Agitation is common and problematic in care home residents with dementia. This study investigated the (cost)effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation in this population. Method Pragmatic, cluster randomised controlled trial with cost-effectiveness analysis in 50 care homes, follow-up at 6 and 16 months and stratified randomisation to intervention (n = 31) and control (n = 19). Residents with dementia were recruited at baseline (n = 726) and 16 months (n = 261). Clusters were not blinded to allocation. Three DCM cycles were scheduled, delivered by two trained staff per home. Cycle one was supported by an external DCM expert. Agitation (Cohen-Mansfield Agitation Inventory (CMAI)) at 16 months was the primary outcome. Results DCM was not superior to control on any outcomes (cross-sectional sample n = 675: 287 control, 388 intervention). The adjusted mean CMAI score difference was –2.11 points (95% CI –4.66 to 0.44, p = 0.104, adjusted ICC control = 0, intervention 0.001). Sensitivity analyses supported the primary analysis. Incremental cost per unit improvement in CMAI and QALYs (intervention vs control) on closed-cohort baseline recruited sample (n = 726, 418 intervention, 308 control) was £289 and £60,627 respectively. Loss to follow-up at 16 months in the original cohort was 312/726 (43·0%) mainly (87·2%) due to deaths. Intervention dose was low with only a quarter of homes completing more than one DCM cycle. Conclusion No benefits of DCM were evidenced. Low intervention dose indicates standard care homes may be insufficiently resourced to implement DCM. Alternative models of implementation, or other approaches to reducing agitation should be considered.

Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT.

The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required. To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care. A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors. Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub. Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation. Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert. The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life. There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified. The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important. There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes. Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff. Current Controlled Trials ISRCTN82288852. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

MEASURING EFFECT OF PERSONALIZED MUSIC TO REDUCE BEHAVIORS IN NURSING HOME RESIDENTS WITH DEMENTIA

The purpose of this six-month pilot study was to identify an optimal measurement strategy for assessing the effects of a personalized music program, MUSIC & MEMORY, on agitated and aggressive behaviors among 45 nursing home residents with moderate to severe dementia. Dementia-related behaviors were measured before and after the intervention with three methods 1) observationally using the Agitation Behavior Mapping Instrument (ABMI); 2) staff report using the Cohen-Mansfield Agitation Inventory (CMAI); and 3) administratively using Minimum Data Set - Aggressive Behavior Scale (MDS-ABS). ABMI score was 4.4 (standard deviation, SD: 2.3) while not listening to the music and 1.6 (SD: 1.5) while listening to music (p<.01). CMAI score was 61.24 (SD: 16.32) before the music and 51.24 (SD: 16.05) after the music (p<.01). MDS-ABS score was .8 (SD: 1.6) before music and .7 (SD: 1.4) after music (p=.59). Direct observations were most likely to capture behavioral responses, followed by staff interviews. No effect was found using exclusively available administrative data. There is growing interest in identifying and testing non-pharmaceutical alternatives to managing agitated and aggressive behaviors in nursing home residents with dementia. Measurement occurring closest in time to the intervention was most likely to capture responses, but was also most costly, least pragmatic, and most subject to confirmation bias. These findings will inform a large pragmatic trial, beginning Spring 2019.

IMPACT OF ADAPTED DANCE ON MOOD AND PHYSICAL FUNCTION AMONG ALZHEIMER’S DISEASE ASSISTED LIVING RESIDENTS

Neuropsychiatric secondary symptoms and altered physical function are prevalent among persons with Alzheimer’s Disease and related dementia disorders (ADRD) which increase healthcare costs and caregiver burden. Adapted dance is a promising intervention that may improve these symptoms and physical function. The purpose of this study is to test whether 12 weeks of adapted dance (60 min 2x/week) improves agitation, physical function, and reduces caregiver burden. An experimental crossover design will be used. ADRD residents with a Montreal Cognitive Assessment score between 6-26, Timed up and go of <20 seconds, Cohen-Mansfield Agitation Inventory Score (CMAI) of >15, and do not use oxygen or assistive device will be eligible to participate. Outcomes will be assessed at baseline and every 4 weeks during each study arm for 24 weeks. Measures include CMAI and the Neuropsychiatric Inventory-Clinician Scale for agitation; Short Physical Performance Battery for physical function; and Zarit Burden Interview for caregiver burden.

Optimizing Practices, Use, Care and Services–Antipsychotics (OPUS-AP) in Long-term Care Centers in Québec, Canada: A Strategy for Best Practices

ObjectivesAntipsychotic medications are often used for the first-line management of behavioral and psychological symptoms of dementia (BPSD) contrary to guideline recommendations. The Optimizing Practices, Use, Care and Services–Antipsychotics (OPUS-AP) strategy aims to improve the well-being of long-term care (LTC) residents with major neurocognitive disorder (MNCD) by implementing a resident-centered approach, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. DesignProspective, closed cohort supplemented by a developmental evaluation. Setting and ParticipantsResidents of designated wards in 24 LTC centers in Québec, Canada. MethodsProvincial guidelines were disseminated, followed by the implementation of an integrated knowledge translation and mobilization strategy, including training, coaching, clinical tools, evaluation of clinical practices, and a change management strategy. Antipsychotic, benzodiazepine, and antidepressant prescriptions; BPSD; and falls were evaluated every 3 months, for 9 months, from January to October 2018. Semistructured interviews (n = 20) were conducted with LTC teams to evaluate the implementation of OPUS-AP. ResultsOf 1054 residents, 78.3% had an MNCD diagnosis and 51.7% an antipsychotic prescription. The cohort included 464 residents with both MNCD and antipsychotic prescription. Antipsychotic deprescribing (cessation or dose decrease) was attempted in 220 of the 344 residents still admitted at 9 months. Complete cessation was observed in 116 of these residents (52.7%) and dose reduction in 72 (32.7%), for a total of 188 residents (85.5%; 95% confidence interval: 80.1%, 89.8%). A decrease in benzodiazepine prescriptions and improvements in Cohen-Mansfield Agitation Inventory scores were observed among residents who had their antipsychotics deprescribed. Caregivers and clinicians expressed satisfaction as a result of observing an improved quality of life among residents. Conclusions and ImplicationsAntipsychotic deprescribing was successful in a vast majority of LTC residents with MNCD without worsening of BPSD. Based on this success, phase 2 of OPUS-AP is now under way in 129 LTC centers in Québec.