Effects of a Stepwise Multidisciplinary Intervention for Challenging Behavior in Advanced Dementia: A Cluster Randomized Controlled Trial

Abstract

Objectives: To assess whether implementation of a stepwise multicomponent intervention (STA OP!) is effective in reducing challenging behavior and depression in nursing home residents with advanced dementia.

Design: Cluster randomized controlled trial.

Setting: Twenty-one clusters (single independent nursing home units) in 12 nursing homes within the Netherlands.

Participants: Residents with advanced dementia (N = 288).

Intervention: Staff working on intervention units received comprehensive stepwise multidisciplinary training; the control condition received training on general nursing skills, dementia management and pain without the stepwise component.

Measurements: The primary outcome was agitation (Cohen-Mansfield Agitation Inventory (CMAI)). Secondary outcomes included psychotropic medication use, neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and symptoms of depression (Cornell Scale for Depression in Dementia (CSDD), Minimum Dataset Depression Rating Scale (MDS-DRS)). Measurements were made at baseline and 3 and 6 months after the intervention. Multilevel analysis and logistical generalized estimating equations were used to test treatment and time effects. Analysis was on an intention-to-treat basis.

Results: Multilevel modeling revealed an overall effect of the intervention on challenging behavior and depression; CMAI (mean difference -4.07 points, 95% confidence interval = (CI) = -7.90 to -0.24, P = .02), NPI-NH (mean difference -3.57 points, 95% CI = -6.30 to -0.84, P = .005), CSDD (mean difference -1.59 points, 95% CI = -2.49 to -0.69, P < .001), and MDS-DRS (mean difference -0.96 points, 95% CI = -1.40 to -0.52, P < .001) scores were significantly lower in the intervention condition than the control condition. There was a significant reduction of antidepressants (N06A) (OR = 0.32); nonsignificant reductions of antipsychotics (N05A), anxiolytics (N05B), and hypnotic-sedatives (N05C) (odds ratios = 0.69 to 0.90).

Conclusion: For nursing home residents with advanced dementia and challenging behavior, providing staff with comprehensive training in behavioral management, resulted in improved behavior and less psychotropic medication use.

Keywords: challenging behavior; dementia; nursing home; psychotropic drug use; stepwise approach.