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Meta-Analysis
. 2012 Feb 15;2012(2):CD006929.
doi: 10.1002/14651858.CD006929.pub2.

Functional analysis-based interventions for challenging behaviour in dementia

Esme D Moniz Cook  1 , Katie Swift, Ian James, Reem Malouf, Marjolein De Vugt, Frans Verhey
Affiliations
Meta-Analysis

Functional analysis-based interventions for challenging behaviour in dementia

Esme D Moniz Cook et al. Cochrane Database Syst Rev. .

Abstract

Background: Functional analysis (FA) for the management of challenging behaviour is a promising behavioural intervention that involves exploring the meaning or purpose of an individual's behaviour. It extends the 'ABC' approach of behavioural analysis, to overcome the restriction of having to derive a single explanatory hypothesis for the person's behaviour. It is seen as a first line alternative to traditional pharmacological management for agitation and aggression. FA typically requires the therapist to develop and evaluate hypotheses-driven strategies that aid family and staff caregivers to reduce or resolve a person's distress and its associated behavioural manifestations.

Objectives: To assess the effects of functional analysis-based interventions for people with dementia (and their caregivers) living in their own home or in other settings.

Search methods: We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 3 March 2011 using the terms: FA, behaviour (intervention, management, modification), BPSD, psychosocial and Dementia.

Selection criteria: Randomised controlled trials (RCTs) with reported behavioural outcomes that could be associated with functional analysis for the management of challenging behaviour in dementia.

Data collection and analysis: Four reviewers selected trials for inclusion. Two reviewers worked independently to extract data and assess trial quality, including bias. Meta-analyses for reported incidence, frequency, severity of care recipient challenging behaviour and mood (primary outcomes) and caregiver reaction, burden and mood were performed. Details of adverse effects were noted.

Main results: Eighteen trials are included in the review. The majority were in family care settings. For fourteen studies, FA was just one aspect of a broad multi-component programme of care. Assessing the effect of FA was compromised by ill-defined protocols for the duration of component parts of these programmes (i.e. frequency of the intervention or actual time spent). Therefore, establishing the real effect of the FA component was not possible.Overall, positive effects were noted at post-intervention for the frequency of reported challenging behaviour (but not for incidence or severity) and for caregiver reaction (but not burden or depression). These effects were not seen at follow-up.

Authors' conclusions: The delivery of FA has been incorporated within wide ranging multi-component programmes and study designs have varied according to setting - i.e. family care, care homes and hospital, with surprisingly few studies located in care homes. Our findings suggest potential beneficial effects of multi-component interventions, which utilise FA. Whilst functional analysis for challenging behaviour in dementia care shows promise, it is too early to draw conclusions about its efficacy.

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Conflict of interest statement

Esme Moniz‐Cook

Prof. Moniz‐Cook is an author of a study included in the review (Moniz‐Cook 2008a).

Esme Moniz‐Cook is chief investigator for two ongoing studies‐ Challenge DemCare Projects ‐ that relate to this review.

Ian James

Ian James is an author of a study included in the review (Fossey 2006). Ian James is co‐investigator for two ongoing studies ‐ Challenge DemCare Projects ‐ that relate to this review.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Forest plot of comparison: 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, outcome: 1.1 Incidence of problem behaviours ‐ family care only. [Instruments used: RMPBC]
3
3
Forest plot of comparison: 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, outcome: 1.2 Frequency of problem behaviours. [Instruments used: PC, RAGE, RMBPC, CMAI and MBCL]
4
4
Forest plot of comparison: 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, outcome: 1.3 Severity of problem behaviours. [Instruments used:  PAS, NPI, Behave‐AD and Crichton Royal Behavioural Scale].
5
5
Forest plot of comparison: 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, outcome: 1.4 Patient depression. [Instruments used: RMPBC Depression sub scale, AGECAT and CDDS]
6
6
Forest plot of comparison: 3 Functional analysis versus usual care ‐ secondary outcomes at post‐intervention, outcome: 3.1 Caregiver reaction. [Instruments used: PC, RMBPC ‐reaction, NPI ‐distress and ABID ‐reaction].
1.1
1.1. Analysis
Comparison 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, Outcome 1 Incidence of problem behaviours ‐ family care only.
1.2
1.2. Analysis
Comparison 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, Outcome 2 Frequency of problem behaviours.
1.3
1.3. Analysis
Comparison 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, Outcome 3 Severity of problem behaviours.
1.4
1.4. Analysis
Comparison 1 Functional analysis versus usual care ‐ primary outcomes at post‐intervention, Outcome 4 Patient depression.
2.1
2.1. Analysis
Comparison 2 Functional analysis versus usual care ‐ primary outcomes at follow‐up, Outcome 1 Incidence of problem behaviours ‐ family care only at 6 month follow‐up.
2.2
2.2. Analysis
Comparison 2 Functional analysis versus usual care ‐ primary outcomes at follow‐up, Outcome 2 Frequency of problem behaviours at 6 month follow‐up.
2.3
2.3. Analysis
Comparison 2 Functional analysis versus usual care ‐ primary outcomes at follow‐up, Outcome 3 Frequency of problem behaviours at 12 month follow‐up.
3.1
3.1. Analysis
Comparison 3 Functional analysis versus usual care ‐ secondary outcomes at post‐intervention, Outcome 1 Caregiver reaction.
3.2
3.2. Analysis
Comparison 3 Functional analysis versus usual care ‐ secondary outcomes at post‐intervention, Outcome 2 Caregiver burden.
3.3
3.3. Analysis
Comparison 3 Functional analysis versus usual care ‐ secondary outcomes at post‐intervention, Outcome 3 Caregiver well‐being (depression).
4.1
4.1. Analysis
Comparison 4 Functional analysis versus usual care ‐ secondary outcomes at 6 month follow‐up, Outcome 1 Caregiver reaction.
4.2
4.2. Analysis
Comparison 4 Functional analysis versus usual care ‐ secondary outcomes at 6 month follow‐up, Outcome 2 Caregiver burden.
4.3
4.3. Analysis
Comparison 4 Functional analysis versus usual care ‐ secondary outcomes at 6 month follow‐up, Outcome 3 Caregiver well‐being (depression).
5.1
5.1. Analysis
Comparison 5 Functional analysis versus usual care ‐ outcomes for behaviour management studies only at post‐intervention, Outcome 1 Frequency of problem behaviours at post‐intervention.
5.2
5.2. Analysis
Comparison 5 Functional analysis versus usual care ‐ outcomes for behaviour management studies only at post‐intervention, Outcome 2 Severity of problem behaviours at post‐intervention.
5.3
5.3. Analysis
Comparison 5 Functional analysis versus usual care ‐ outcomes for behaviour management studies only at post‐intervention, Outcome 3 Caregiver burden at post‐intervention.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Mittleman 2006 {published data only}
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Schrijnemaekers 2002 {published data only}
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Schulz 2003 {published data only}
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