Holistic, person-centered care can reduce symptoms of agitation in dementia patients, compared with the effects of standard long-term care, a randomized controlled trial by Australian researchers indicates.
Focusing on the patient as a whole and seeking to make the most of his or her remaining abilities is also economical and easy to implement, the researchers recently reported (Lancet Neurol. 2009;8:317-25).
“Care that addresses residents' total human needs can mitigate cognitive and functional deterioration,” asserted the team led by Lynn Chenoweth, Ph.D., of the University of New South Wales, Sydney.
The Caring for Aged Dementia Care Residents Study (CADRES) was composed of 289 residents living in 15 Australian long-term care facilities. All of the residents had progressive dementia with persistent behaviors that made it difficult for staff to care for them.
The facilities were randomized to three interventions: usual care, person-centered care, and dementia-care mapping, which includes person-centered care.
The researchers provided staff training in the facilities randomized to one of the experimental plans. The person-centered care training consisted of a 2-day session for two staff members of each facility, who then developed and implemented practices in their respective facilities. Training stressed that behavior is a form of communication and that feelings persist in individuals despite cognitive decline.
Trainees were encouraged to focus on “the unique way those residents express feelings and needs” and how staff actions could address individuals' preferences and needs.
Dementia-mapping care training also consisted of a 2-day session for two staff members per facility, and they, too, then helped their colleagues implement the approach.
This system of care entails observation of which care factors most affect resident behavior, either negatively or positively. Daily observations are then integrated into a person-centered care plan.
Care continued as usual at the control sites, characterized by custodial tasks, physical restraint, and “a tendency to neglect residents' psychosocial needs when meeting activities of daily living,” according to the researchers. Staff at these facilities paid little attention to promoting choice and encouraging self-determination by residents with dementia, according to Dr. Chenoweth and her colleagues.
Outcome measures included the 29-item Cohen-Mansfield Agitation Inventory (CMAI), the Neuropsychiatric Inventory for the Nursing Home, and the Quality of Life in Late-Stage Dementia (QUALID) scale. Outcomes were measured at baseline, after 4 months of intervention that included telephone support by the researchers, and again 4 months after that (8 months after the start of the study).
The patients' average age at baseline was 84 years. Their average dementia score was 5.2 on the Global Deterioration Scale, indicating moderate dementia, according to the researchers.
At 4 and 8 months, agitation had increased in the control group but decreased in residents under the experimental care approaches.
The standard-care residents' CMAI scores went up 9 points on average at 4 months and 8 points at 8 months. In contrast, the agitation scores went down 6 points by the study's end (8 months) in the person-centered care recipients and by 2 points in the dementia-care mapping group.
The neuropsychiatric inventory score decreased significantly only in the person-centered care group, where it dropped a mean of almost 7 points at 4 months and another 2 points at 8 months.
There was no significant change in the quality of life scores for any group. Nor was there any indication that either experimental care approach decreased accidents, hospital admissions, drug costs, or the need for psychotropic medications.
However, the investigators noted, the dementia-care mapping group did experience a significant decrease in the number of falls, while the person-centered care and usual care groups saw increases in falls.
The costs of implementing the care programs differed significantly. The additional cost per site for dementia-mapping care was $6,654, compared with $1,492 for person-centered care. The researchers also estimated the cost per average point drop in agitation on the CMAI scale. Again, person-centered care was more economical than dementia-mapping care ($5.30 vs. $32.46, respectively).
The study affirmed previous findings that person-centered care is a valuable way to decrease agitation in dementia patients without resorting to drugs, Dr. Clive Ballard and Dr. Dag Aarsland, both of King's College, London, wrote in an editorial accompanying the report.
They added that the study also provided valuable information about the usefulness of dementia-mapping care, which had not been fully investigated.
The commenters offered a few caveats about the CADRES study, saying that any intervention can result in nonspecific benefits when compared with standard care.
Also, the study period was too short to fully determine the possible benefit of each intervention, wrote Dr. Ballard and Dr. Aarsland.