Neuropsychiatric Inventory-Nursing Home Version Research Articles

Impact of Pain and Neuropsychiatric Symptoms on Activities in Nursing Home Residents (COSMOS Trial)

ObjectiveThis study aims to identify whether pain and dementia-related behavior are associated with different types of activities in nursing home residents, controlled for dementia severity. DesignCross-sectional baseline data from the multicomponent cluster randomized controlled COSMOS trial (acronym for Communication, Systematic pain treatment, Medication review, Organization of activities, and Safety). Setting and ParticipantsA total of 723 patients from 33 Norwegian nursing homes with 67 units (clusters). Participants aged ≥65 years, with a life expectancy of >6 months, and with valid data on activity were eligible for inclusion. MethodsActivity was operationalized in time (hours per week) and type (cognitive, social, physical, and no activity). Cognitive function was assessed using the Mini-Mental State Examination (MMSE), pain with the Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale (MOBID-2), and behavior with the Neuropsychiatric Inventory Nursing Home version (NPI-NH). Analyses were performed using linear and logistic regression. Sensitivity analyses for dementia severity were performed to account for effect modification. ResultsA total of 289 participants were included (mean age 86.2 [SD 7.6]; 74% female). A higher pain score was associated with less time spent on activity in participants with severe dementia (estimate 0.897, P = .043). A higher score for the NPI-NH mood cluster (depression and anxiety) was associated with a higher likelihood of participation in cognitive activities (odds ratio [OR], 1.073; P = .039). Apathy (OR, 0.884; P = .041) and lack of inhibition (OR, 0.904; P = .042) were associated with a lower likelihood of participation in social activities as well as no engagement in activities (apathy OR, 0.880; P = .042; lack of inhibition OR, 0.894; P = .034). Conclusion and ImplicationsPain and dementia-related behavior may influence the participation in activities in the nursing home. There is an urgent need to investigate what type of activity stimulates people in different stages of dementia.

A short staff training system for behavioural and psychological symptoms of dementia in care facilities, based on functional analysis and positive behaviour support: a single-arm pre- and post-comparative study.

Work schedules can make it challenging for professional care workers to participate in long-term training programs on managing behavioural and psychological symptoms of dementia (BPSD). Simultaneously, it is necessary to prevent caregivers' negative responses to BPSD, provide a positive environment for people with dementia, and create a system for new management plans, since the initial one is often unsuccessful. Therefore, we developed a short manual-based training system for functional analysis including positive behaviour support and strategies when management plans do not function well. This study aimed to preliminarily examine the usefulness of this system. Thirty-five staff members from 12 care facilities participated in the training. For each facility, off-the-job training was performed in two 120-min sessions held over 2 days. Then, care plans were implemented by staff members for a month, during which on-the-job training was provided. The study included 14 people with dementia and BPSD. This was a single-arm study without a control group. Pre- and post-tests were conducted to examine the effects of the training system using the Neuropsychiatric Inventory-Nursing Home Version. The results of the pre- and post-tests for the total scores on severity and occupational disruptiveness significantly improved, with large effect sizes. Regarding symptom domains, delusions, agitation/aggression, and aberrant motor behaviour significantly improved in both severity and occupational disruptiveness. Depression/dysphoria and anxiety significantly improved in severity; however, there were trends of improvement in occupational disruptiveness. In addition, the effect sizes for severity and occupational disruptiveness of delusions and agitation/aggression were large. This preliminary study suggests that the training system is promising. A randomised controlled trial with a larger sample size is necessary to confirm the findings.

ASSOCIATION BETWEEN MOTOR ACTIVITY AND TOTAL NEUROPSYCHIATRIC INVENTORY NURSING HOME VERSION SCORES

Abstract Accurate neuropsychiatric symptoms (NPS) assessment monitoring is crucial for person-centered dementia care management. Doing so, however, is challenging, since current assessment tools rely on clinical observations, are time consuming, and are somewhat subjective in nature. The Neuropsychiatric Inventory Nursing Home Version (NPI-NH) is an informant-based assessment of 10 sub-domains of behavioral functioning where total NPI-NH score represents an overall behavioral disturbance level. We investigated the evidence pertaining to the diagnostic test accuracy (DTA) of motor activity tracking obtained via wearable sensor technology (WST) using total NPI-NH score as the gold standard in persons living with dementia (PLWD). This was part of a larger systematic review assessing the use of WST for NPS detection and monitoring carried out from inception until September 2022 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219917). A systematic literature search carried out in 7 library databases produced 12,928 articles from which 84 titles were retained for analysis. In total, 8 articles examined the validity of WST for assessing and monitoring of overall behavioral disturbance in PLWD, among which 5 studies used motor activity trackers. Dementia participants predominantly had Alzheimer’s, vascular or mixed dementia (40%, 20%, and 40% respectively), with mild-moderate severity. Three studies reported correlations between motor activity and total NPI score that ranged from 0.35 to 0.38. A random effects model indicated that the pooled correlation across studies was 0.37 (0.22-0.51), with no heterogeneity (I2=0%). While our sample reveals WST test accuracy as being consistently moderate, more research is necessary for confirmation.

Feasibility of Using Wearable Actigraphy for Behavioural Monitoring in Care Home Residents Living with Moderate to Severe Alzheimer’s Disease and Agitation

AbstractBackgroundMeasuring and monitoring behaviour is difficult in people living with later stage Alzheimer’s disease and specific behavioural symptoms such as agitation and aggression (AA). Currently, subjective information given by these patients is highly susceptible to inaccurate recall, clinicians rely on answers provided by care givers, which can be biased and lack fine‐grain temporal detail. Although actigraphy watches have been useful tools for research, little is known about the feasibility of their use in agitated dementia participants and on the factors influencing watch compliance.MethodPeople diagnosed with Alzheimer’s disease and significant AA symptoms living in care homes were asked to wear an actigraphy watch (GENEactiv Original) for 4 consecutive weeks. Demographic data, Functional Assessment Staging Tool (FAST) score, behavioural symptom pattern and severity were recorded using the Neuropsychiatric Inventory Nursing Home Version (NPI‐NH). Watch‐recorded wearing time and activity data were used to evaluate adherence. Care home staff were interviewed to explore factors influencing watch wearing by participants and to develop solutions to improve compliance.ResultWe recruited 28 participants (14 female) and found wearing the watch feasible overall. No statistical compliance difference was found between different groups based on age, FAST score, agitation pattern or severity; however, a significant gender difference was found with male participants being more adherent (Table). Participants were more compliant in weeks 3‐4, and first week adherence predicted overall adherence (Figure). Factors influencing compliance include the design and appearance of the watch, previous watch wearing habit, and the perceived purpose of the study. Using documents easily readable to participants and care givers to facilitate understanding of the study and to communicate challenging clinical scenarios appeared to enhance adherence.ConclusionWearing an actigraphy watch for behavioural monitoring was feasible for moderate to severe Alzheimer’s disease patients with AA symptoms in care home settings. Gender‐specific design and appearance should be considered when selecting the actigraphy watch. For dementia studies planning to use an actigraphy watch, compliance can be improved by incorporating a short lead‐in phase to establish a watch wearing routine and by providing reader‐friendly documents about the watch purpose to communicate with participants and care givers.

Agitation and aggression in people living with dementia and mild cognitive impairment in shared-housing arrangements – validation of a German version of the Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF)

BackgroundThe Cohen-Mansfield Agitation Inventory-Short Form (CMAI-SF) is a 14-item scale for assessing agitation and aggression, derived from the original 29-item CMAI, and completed by a proxy. Because the CMAI-SF has not yet been validated in German language, the aim of this study is to explore its construct validity.MethodsBaseline data from a cluster-randomized trial to evaluate a non-pharmacological complex intervention for people living with dementia (PlwD) and mild cognitive impairment (MCI) were analyzed. The study sample consisted of 97 shared-housing arrangements (SHAs) in Germany, comprising N = 341 residents with mild to severe dementia and MCI. Trained nursing staff collected data by proxy-rating the CMAI-SF, Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), and QUALIDEM. They also conducted the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).ResultsIn an exploratory factor analysis, three factors emerged: “aggressive behavior”, “verbally agitated behavior”, and “physically non-aggressive behavior”. The CMAI-SF total score showed good internal consistency (α = .85), and the factors themselves showed adequate internal consistency (α = .75/.76/.73). The CMAI-SF showed convergent validity with the NPI-NH agitation item (r = .66) and the NPI-NH “agitation & restless behavior” factor (r = .82). Discriminant validity was confirmed by a low (r = .28) correlation with the NPI-NH apathy item. Quality of life decreased significantly with agitation, as the CMAI-SF showed a moderate negative correlation with the QUALIDEM total score (r = -.35).ConclusionsThe 14-item CMAI-SF is a time-efficient, reliable, and valid assessment instrument. Three factors emerged that were similar to those already found in nursing home samples for the original CMAI and the CMAI-SF and in day care samples for the CMAI-SF. The findings provide preliminary evidence that the CMAI-SF can be used instead of the CMAI to reduce time, costs, and burden in future trials.Trial registrationThe DemWG study from which data were used to draft this manuscript was prospectively registered on 16 July 2019 at ISRCTN registry (ISRCTN89825211).

Traditional Chinese medicine Jia Wei Gui Pi Tang improves behavioural and psychological symptoms of dementia and favourable positive emotions in patients

Behavioural and psychological symptoms of dementia (BPSD) are challenging to manage, leading to caregiver burden and often to subsequent transfer of patients to a nursing home or psychiatric hospital for treatment. Eliciting favourable positive emotions should be an important goal in the treatment of negative emotions associated with BPSD. To date, no data have indicated that antipsychotic medications can improve positive emotions. BPSD are known to be associated with anxiety in patients with dementia. The traditional Chinese medicine Jia Wei Gui Pi Tang is officially indicated and approved for anxiety treatment in Japan. Here, we performed a multicentre, randomised, observer-blind control study of the effect of Jia Wei Gui Pi Tang on BPSD in Alzheimer's disease (AD) patients. Patients with AD or AD with cerebral vascular disease were randomly divided into the Jia Wei Gui Pi Tang treatment group and the control group that received no traditional Chinese medicine. BPSD were scored using the Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and by favourable positive emotions using the Delightful Emotional Index (DEI). A total of 63 participants (18 male and 45 female; mean age: 83.3 ± 6.0 years) were included in the study. Changes in NPI-NH scores differed significantly between the two groups (one-way analysis of variance, P < 0.001). Within the treatment group, there was a significant improvement in the NPI-NH score from 29.8 ± 17.3 at baseline to 13.2 ± 9.4 at the endpoint (paired t-test, P < 0.001), whereas there was no statistically significant change in the control group. Changes in DEI scores differed significantly between the two groups. Within the treatment group, there was a significant improvement in the DEI score from 24.3 ± 23.0 at baseline to 32.5 ± 21.2 at the endpoint (paired t-test, P = 0.001), whereas there was no statistically significant change in the control group. The traditional Chinese medicine Jia Wei Gui Pi Tang significantly improved both BPSD and positive emotions.

Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART.

Auditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia. A 15-month, stepped-wedge, cluster-randomized trial. Every 3months, a nursing home switched from care as usual to the use of the intervention. The 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents. We included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness. The primary outcome was NPS severity measured with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) by the resident's primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction). The mean age of the residents (n= 97) at enrollment was 86.5 ± 6.7years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (-8.0, 95% CI -11.7,-2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI -0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (-0.3, 95% CI -0.3, 0.8), or staff job satisfaction (-0.2, 95% CI -1.2, 0.7). MoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.

Impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic prescribing for people with dementia in nursing home settings.

This study aimed to determine the impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic use in people with dementia living in nursing homes. This was a comparative analysis of baseline data from two large nursing home studies, one conducted during (COVID-iWHELD study) and one prior (WHELD study) to the pandemic. It involves data from 69 and 149 nursing homes, and 1006 and 666 participants respectively. Participants were people with established dementia (score >1 on Clinical Dementia Rating Scale). Resident data included demographics, antipsychotic prescriptions and neuropsychiatric symptoms using the Neuropsychiatric Inventory Nursing Home version. Nursing home data collected were nursing home size and staffing information. Overall prevalence of neuropsychiatric symptoms was unchanged from pre-pandemic prevalence. Mean antipsychotic use across the sample was 32.0%, increased from 18% pre-pandemic (Fisher's exact test p<0.0001). At a nursing home level, the medians for the low, medium and high tertiles for antipsychotic use were 7%, 20% and 59% respectively, showing a disproportionate rise in tertile three. Residents in these homes also showed a small but significant increase in agitation. There has been a significant increase in antipsychotic prescribing in nursing homes since the COVID-19 pandemic, with a disproportionate rise in one third of homes, where median prescription rates for antipsychotics were almost 60%. Strategies are urgently needed to identify these nursing homes and introduce pro-active support to bring antipsychotic prescription rates back to pre-pandemic levels.

Antipsychotic prescriptions and neuropsychiatric symptoms (NPS) in nursing home (NH)residents with dementia: a comparison of pre‐ and during COVID pandemic.

AbstractBackgroundThe COVID‐19 pandemic has put tremendous pressures on nursing homes, but there is limited direct data evaluating the impact on residents or prescribing practicesMethodAs part of our clinical trial programme in nursing homes we have baseline data from 971 residents across 69 nursing homes collected in 2016/17 prior to the pandemic, and from 747 participants across 149 nursing homes from the baseline assessment of our COIVD WHELD RCT collected in 2021/22. In both studies the frequency if antipsychotic prescriptions was recorded and the Neuropsychiatric Inventory Nursing Home version was completed.ResultsThe average age of residents (84.5 v 85.1) and gender balance (71%F v 69% F) was similar in both cohorts. In the current study 64% of participating nursing homes had experienced a COVID‐19 outbreak. There were fewer people with severe dementia in the COVID WHELD Cohort (6.7% v 23%). Antipsychotic usage was 55% higher in the COVID WHELD cohort compared to the original WHELD cohort (28% v 18%), with 25% of nursing homes having prescription rates &gt;40%, but the rates of neuropsychiatric symptoms were similar in the 2 studies. To ensure that the results were not confounded by the lower number of people with severe dementia in the COVID WHELD cohort, a further comparison was undertaken for people with moderate/moderately severe dementia, with very similar results. We undertook an additional analysis comparing nursing homes above and below prescription rates of 20% (the pre‐COVID level of prescribing). Nursing homes with increased antipsychotic prescribing had significantly higher levels of overall neuropsychiatric symptoms on the NPI (p = 0.02), and significantly higher levels of agitation (p = 0.02) compared to nursing homes with lower prescribing rates. There were also 31% more staff sick days in the higher prescribing nursing homes.ConclusionThere is a substantial increase in antipsychotic prescriptions in 50% of nursing homes since the onset of the COVID‐19 pandemic, associated in those nursing homes with an increase in neuropsychiatric symptoms. This will need to be a major focus as we begin to move forward from the pandemic.

Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial

ObjectivesTo investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia.MethodsBaseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care.MeasurementsThe primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio.ResultsGeneralized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed.ConclusionFor nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers’ engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs.Trial registrationClinicalTrials.gov; NCT02238652.

Study design of an interdisciplinary and participatory nature-based palliative rehabilitation intervention in a Danish nursing home for people with severe dementia

BackgroundA limited amount of research has examined how nature-based palliative rehabilitation can be implemented in nursing homes for people with dementia, even though evidence suggests that these gardens are underused. This paper will present the study protocol of an intervention study co-designed in an interdisciplinary collaboration with a nursing home for people with dementia, to develop a tailored nature-based palliative rehabilitation program to increase qualified use of garden with the purpose of promoting a range of health outcomes.MethodsThe study is a single-cased quasi-experimental mixed methods study. The intervention will be developed, designed, and implemented in collaboration with the nursing home, using different co-design tools and methods. The effect of the intervention will be evaluated using the The Neuropsychiatric Inventory Nursing Home version in combination with medication use, a survey on staff burnout, and cameras in the garden to register garden use. A process evaluation with single- and focus group interviews consisting of various stakeholders in the study will be used to gain knowledge on the intervention processes and implementation.DiscussionThe paper presents new approaches in the field of palliative rehabilitation for people with dementia using nursing home gardens, through interdisciplinary collaboration, participatory co-design approach and mixed methods design. Using both effect and process evaluation, the study will provide unique insights in the role and importance of participatory process, interdisciplinary collaboration, and tailoring palliative rehabilitation activities in gardens at nursing homes to local needs and wishes. These results can be used to guide other nursing homes and renewal projects in the future.Trial registrationISRCTN, ISRCTN14095773. Registered 15 July 2022—Retrospectively registered.

Neurologic Music Therapy with a Habilitative Approach for Older Adults with Dementia: A Feasibility Study

Abstract The incidence of dementia continues to increase in our aging population. Numerous cognitive, behavioral, and psychological symptoms accompany this diagnosis, and the need for non-pharmacological interventions that may alleviate them is of paramount importance. This feasibility study presents the results of a crossover randomized control trial that evaluated the effects of neurologic music therapy with a habilitative approach on the treatment acceptability, cognition, mood, and behavior of older adults with moderate to severe dementia. Twenty-nine residents living in an assisted living community rotated between 50-minute group sessions of Neurologic Music Therapy (NMT) techniques implemented with a habilitative approach, an Enrichment Program (EP) that combined physical and cognitive exercises, and a non-facilitated television program (TV). Data were collected before and after each crossover period using attendance, the Neuropsychiatric Inventory-Nursing Home (NPI-NH) version, the Dementia Mood Picture Test (DMPT), and the Montreal Cognitive Assessment (MoCA). NMT had the highest level of treatment acceptability, as measured by attendance and adherence. NPI-NH scores were the lowest after TV viewings, and DMPT results were the highest after NMT, followed by EP and TV. The positive effect of NMT on general cognitive functioning for residents with moderately severe cognitive decline was remarkable. These results suggest that NMT with a habilitative approach is a viable tool to engage older adults with dementia. The promising results on cognition and its high treatment acceptability make a powerful case to increase NMT use with this population and continue studying its effectiveness.

THE DANTON STUDY - DISCONTINUATION OF ANTIHYPERTENSIVE TREATMENT IN OLDER PEOPLE WITH DEMENTIA LIVING IN A NURSING HOME: RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Objective: Neuropsychiatric symptoms (NPS), such as apathy and agitation, are highly prevalent in nursing home (NH) residents with dementia. Literature suggests an association of both cerebral hypoperfusion and antihypertensive treatment (AHT) with NPS in patients with dementia. Therefore, we investigated whether discontinuation of AHT in NH residents with dementia reduces NPS and improves quality of life (QoL). Design and method: Randomized, single-blinded trial conducted in 26 Dutch NH organisations. Residents with moderate-severe dementia and a systolic blood pressure &lt; 160 mmHg during AHT were randomized in an intervention (semi-protocolized discontinuation) and control (continuation) group during a period of 8 months. Exclusion criteria were heart failure NYHA-class-III/IV, angina pectoris, a recent cardiovascular event/reperfusion procedure, or a life-expectancy &lt; 4 months. Co-primary endpoints were NPS (Neuropsychiatric Inventory-Nursing Home version) and QoL (Qualidem) at 4 months. Secondary endpoints include cognitive function, care dependency, general daily functioning and falls. Results: Between December 2018 and May 2021, 205 NH residents with dementia (median age 86 years-79.5% women) were randomized, of which 177 (86.3%) reached the primary endpoint at 4 months. During trial, 63 severe adverse events occurred in 61 residents. On advice of the Data Safety Monitoring Board, the study was preliminary finished in December 2021 due to futility based on the co-primary endpoints. Definitive results for all endpoints measured at 4 and 8 months follow-up will be available in April 2022. Conclusions: This is, to our knowledge, the largest AHT deprescription trial in NH residents with dementia. Based on preliminary results of this study, the benefits of deprescribing AHT in NH residents with dementia for reduction of NPS and improvement of QoL, are unclear and may not be without any potential risk.

Understanding Pain and Agitation Through System Analysis Algorithms in People With Dementia. A Novel Explorative Approach by the DIGI.PAIN Study.

BackgroundMany people with dementia (PwD) live and die with undiagnosed and untreated pain and are no longer able to report their suffering. Several pain assessment tools have been developed, tested, and implemented in clinical practice, but nursing home patients are reported to be still in pain. Clinicians and research groups worldwide are seeking novel approaches to encode the prediction, prevalence, and associations to pain in PwD.ParticipantsThe data in this analysis are acquired from the COSMOS study, a cluster-randomized controlled trial (2014 to 2015), aimed to improve the quality of life in nursing home patients (N = 723) through the implementation of a multicomponent intervention. We utilize baseline data of PwD (N = 219) with complete datasets of pain and agitation.MethodSystems analysis explores the relationship between pain and agitation using the Mobilization-Observation-Behavior-Intensity-Dementia (MOBID-2) Pain Scale, Cohen-Mansfield Agitation Inventory (CMAI), and Neuropsychiatric Inventory-Nursing Home version (NPI-NH). For each patient, the individualized continuous time trajectory, and rates of change of pain and agitation are estimated. We determine the relationship between these rates by analyzing them across the entire group.ResultsWe found that the new analysis method can generate individualized estimations for pain and agitation evolution for PwD, as well as their relationship. For 189 of 219 PwD, results show that whenever pain increases or decreases, agitation does too, with the same rate. The method also identifies PwD for whom pain or agitation remains constant while the other varies over time, and patients for whom agitation and pain do not change together. The algorithm is scalable to other variables and compatible with wearable devices and digital sensors.ConclusionWe presented a new approach to clinical data analysis using systems concepts and algorithms. We found that it is possible to quantify and visualize relationships between variables with a precision only dependent on the precision of measurements. This method should be further validated, but incipient results show great potential, especially for wearable-generated continuous data.

Multicomponent Staff Training Intervention to Improve Residential Dementia Care (PROCUIDA-Demencia): A Mixed-Methods 2-Arm Cluster Randomized Controlled Pilot and Clinical Outcomes Study.

To evaluate the feasibility outcomes of implementing a multicomponent staff training intervention (PROCUIDA-Demencia) to promote psychosocial interventions and reduce antipsychotic prescription in Mexican care homes and study its effect on staff's care experience and residents' quality of life. A mixed-methods 2-arm cluster randomized controlled pilot study of a 2-day staff training program with baseline, 12weeks, and 24weeks of the PROCUIDA-Demencia intervention vs treatment as usual (TAU). Eight care homes in Mexico City were selected, from which 55 residents and 126 staff were recruited. In situ staff training consisting of evidence-based manualized psychosocial interventions of person-centered activities, reminiscence therapy, doll therapy, psychomotor dance therapy, and antipsychotic prescription review. Fidelity to protocol was supervised once a week. Cluster-level feasibility measures included views of staff, residents, and relatives on acceptability, satisfaction, adherence, and fidelity to the intervention. Staff outcome measures were Maslach Burnout Inventory (MBI), Approaches to Dementia Questionnaire, and Sense of Competence in Dementia Care Staff. Residents' outcome measures included Quality of Life-Alzheimer's Disease scale (QoL-AD), and Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). Staff distress was measured using the NPI-NH occupational disturbance scale. Feasibility was elicited through a focus group, and hierarchical linear mixed effects models were used to assess the adjusted effects of the respective measures. Observed medical practice showed the prescription of at least 1 antipsychotic in 41% of participants in the intervention group. Overall, 39% of residents reported discontinuation, and 15% reduction of antipsychotics, following the 12-week medical review in parallel with psychosocial interventions. Clinical outcomes contributed positively to the reduction in baseline staff burden according to the MBI after the intervention [mean difference-8.9, 95% confidence interval (CI)-17.7,-0.1, P= .049] and to the reduction in severity and frequency of behavior as per NPI-NH in residents (mean difference-9.4, 95% CI -17.5,-1.3, P= .025). PROCUIDA-Demencia is a feasible intervention for Mexican care homes. Results contribute to the Mexican Dementia Plan optimizing dementia care by supporting the need for staff training to implement psychosocial interventions prior to prescribing antipsychotic medication.

Development and Evaluation of the Behavioral and Psychological Symptoms of Dementia Questionnaire 13-Item Version (BPSD13Q)

Introduction: Most behavioral and psychological symptoms of dementia (BPSD) scales have copyright issues and are difficult for care staff to use in daily care settings because they were primarily designed for physicians. Therefore, an easier tool for care staff is required. This study aimed to develop and validate the BPSD questionnaire 13-item version (BPSD13Q). Methods: We obtained data from 444 people with dementia living in group homes in Japan using the BPSD plus questionnaire (BPSD + Q; 27-item version) and Neuropsychiatric Inventory Nursing Home version (NPI-NH). We selected appropriate items to make a short-form version of the BPSD + Q and examined the construct validity, internal consistency, and criterion-related validity of the questionnaire. Results: By the pilot review, research on correlations with similar items from comparable scales, and factor analysis, we reduced 27 items to 13 items (BPSD13Q). The BPSD13Q and BPSD13Q-distress (BPSD13Q-D) showed good internal consistency (Cronbach’s α = 0.76 and 0.80, respectively). Moreover, the BPSD13Q was positively correlated with the NPI-NH (r = 0.72, p < 0.001) and BPSD + Q (r = 0.95, p < 0.001). The BPSD13Q-D was positively correlated with the NPI-NH-caregiver distress (r = 0.74, p < 0.001) and BPSD + Q-distress (r = 0.96, p < 0.001). Conclusion: We developed and validated the BPSD13Q, which is a short-form version of the BPSD + Q and is downloadable. The BPSD13Q may make BPSD evaluations easier for the care staff.

The effects of bright light treatment on affective symptoms in people with dementia: a 24-week cluster randomized controlled trial

BackgroundThe majority of people with dementia have behavioral and psychological symptoms of dementia (BPSD), including depression, anxiety and agitation. These may be elicited or aggravated by disrupted circadian rhythms. Bright light treatment (BLT) is a promising non-pharmacological approach to the management of BPSD, but previous research has yielded mixed results.MethodsEight nursing home dementia units (1 unit = 1 cluster) with 78 patients were invited to participate in a cluster randomized controlled trial from September 2017 to April 2018 investigating the effects of BLT on sleep and circadian rhythms (primary outcome) and BPSD (secondary outcome). Ceiling mounted LED-panels were installed in the intervention group (four units), providing light at 1000 lx and 6000 K (vertically at 1.2 m) between 10 a.m. and 3 p.m., with lower values in the mornings and evenings. Standard indoor light was used in the control group (four units). BPSD were assessed with The Cornell Scale for Depression in Dementia (CSDD) and the Neuropsychiatric Inventory Nursing Home Version (NPI-NH). Data collection took place at baseline and after 8, 16 and 24 weeks. Multilevel regression models with and without false discovery rate correction were used for the analysis, with baseline values and dementia stage entered as covariates.ResultsSixty-nine patients were included in the study at baseline. Compared to the control group, the intervention group had a larger reduction on the composite scores of both the CSDD (95% CI = − 6.0 – − 0.3) and the NPI-NH (95% CI = − 2.2 – − 0.1), as well as on the NPI-NH Affect sub-syndrome, and the CSDD Mood related signs sub-scale at follow-up after 16 weeks. With FDR correction, the group difference was significant on the CSDD Mood related signs sub-scale (95% CI = − 2.7 – − 0.8) and the NPI-NH Affect sub-syndrome (95% CI = − 1.6 – − 0.2). No differences were found between conditions at weeks 8 or 24.ConclusionCompared to the control condition, affective symptoms were reduced after 16 weeks in the group receiving BLT, suggesting BLT may be beneficial for nursing home patients with dementia.Trial registrationClinicalTrials.gov Identifier: NCT03357328. Retrospectively registered on November 29, 2017.

Effectiveness of a musical fitness programme for older adults with cognitive impairment in long-term care facilities: A quasi-experimental study.

To investigate the effectiveness of a musical fitness programme (MFP) intervention in improving neuropsychiatric symptoms, depression, upper-limb muscle strength and cognition of older adults with cognitive impairment in long-term care (LTC) facilities. Because of population ageing, the number of older adults with cognitive impairment has been increasing. The effectiveness of medications in treating cognitive impairment is limited; therefore, the global trend has been for non-pharmacological treatments. However, intervention studies of MFPs on older LTC residents with cognitive impairment are scant. This study adopted a quasi-experimental design in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) checklist. In total, 84 older adults with cognitive impairment were recruited from seven LTC facilities. The MFP was implemented from July-November 2019. The intervention group received the MFP, which was 50min per session, twice a week for 12weeks, whereas the comparison group received usual care. Neuropsychiatric inventory nursing home version, the Cornell scale for depression in dementia Chinese version, 30-s arm curl test and Mini-Mental State Examination were the outcome measures. Data were analysed using Chi-square test, t test and repeated measure analysis of variance. After the intervention, the scores of neuropsychiatric inventory and the Cornell depression exhibited significant differences over time between two groups (F=3.6, p=.029; F=5.96, p=.003, respectively). Nevertheless, 30-s arm curl test and Mini-Mental State Examination demonstrated non-significant between-group differences. The MFP can effectively reduce neuropsychiatric symptoms and depression in older adults with cognitive impairment in LTC facilities. To ensure a more robust evidence base, more research is warranted. The MFP is a non-pharmacological treatment that can be implemented to promote psychological well-being among older adults with cognitive impairment in LTC facilities, and to indirectly reduce nursing staff burden. To assist nursing staff in providing this intervention, on-the-job training is needed.

The prevalence and determinants of inappropriate sexual behaviour in people with acquired brain injury in nursing homes.

AimsEstablishing the prevalence of inappropriate sexual behaviour, concurrent challenging behaviours and the determinants of inappropriate sexual behaviour among patients with acquired brain injury ≤65 years of age in Dutch nursing homes.DesignCross‐sectional, observational study in acquired brain injury special care units spreads throughout the country.MethodsNursing homes were recruited through the national expertise network for patients with severe acquired brain injury, regional brain injury teams and by searching the Internet. Patient characteristics were collected through digital questionnaires. Inappropriate sexual behaviour was assessed with the St. Andrews Sexual Behaviour Assessment, concurrent challenging behaviours with the NeuroPsychiatric Inventory‐Nursing Home Version and the Cohen‐Mansfield Agitation Inventory, cognition with the Mini‐Mental State Examination and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and inappropriate sexual behaviour were examined using multilevel multivariate linear regression model analyses. Data collection started in June 2017 and ended in April 2019.ResultsOf the 118 included patients, 38.1% had one or more inappropriate sexual behaviours. Verbal comments (30.1%) and non‐contact behaviour (24.8%) were the most prevalent types of inappropriate sexual behaviour. Less severe behaviours were more common than more severe behaviours. The most frequent concurrent challenging behaviours were agitation, aggression and hyperactivity. Physical aggression was associated with more inappropriate sexual behaviour. Being married and pain were associated with less inappropriate sexual behaviour.ConclusionInappropriate sexual behaviour is prevalent in patients with acquired brain injury ≤65 years of age residing in nursing homes.ImpactInappropriate sexual behaviour may have impact not only on the patients themselves but also on nursing staff. Insight into the magnitude, severity, course and concurrent challenging behaviours, sexuality and quality of life could give direction to the kind of interventions and education that is needed. The ultimate goal is to develop appropriate care for this vulnerable group of patients, specifically psychosocial interventions and appropriate use of psychotropic drugs.

The prevalence and course of neuropsychiatric symptoms in stroke patients impact functional recovery during in-hospital rehabilitation

ABSTRACT Background Neuropsychiatric symptoms are common after stroke and are distressing symptoms. They may persist after the acute event and negatively impact rehabilitation, functioning, and patients' quality of life. Objectives To elucidate the prevalence and course of neuropsychiatric symptoms in stroke patients during rehabilitation, we prospectively investigated the trajectory change of neuropsychiatric symptoms and the association between these symptoms and functional recovery. Methods This observational study enrolled 204 stroke patients consecutively admitted to the rehabilitation ward. We administered the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH) for evaluating the neuropsychiatric symptoms (e.g., apathy and depression) and the Functional Independence Measure (FIM) and Montebello Rehabilitation Factor Score (MRFS) for functional recovery. Results The cumulative prevalence of neuropsychiatric symptoms was 48% during hospitalization; depression, anxiety, and sleep disturbances were most frequent. Binomial logistic regression analyses revealed that the factors associated with deterioration of neuropsychiatric symptoms during hospitalization included premorbid depression (odds ratio: 18.628, P = .001), the length of stay from onset to rehabilitation ward admission (odds ratio: 1.022, P = .012), motor FIM at admission (odds ratio: 0.950, P < .001), and NPI-NH at admission (odds ratio: 0.923, P = .011). Stepwise multiple regression analyses revealed that the NPI-NH at admission was associated with the MRFS (β = −0.128, P = .037). Conclusion Neuropsychiatric symptoms are common in stroke patients undergoing rehabilitation and have a substantially negative impact on rehabilitation outcomes. Stroke patients with prolonged acute-phase hospitalization and low functioning at admission must be monitored to detect any deterioration in the neuropsychiatric state.