A non-pharmacologic approach to address challenging behaviors of Veterans with dementia: description of the tailored activity program-VA randomized trial

BMC Geriatrics

Paul B Arthur²  W Bruce Vogel³  William C Mann²  Laura N Gitlin¹ 

[1] Johns Hopkins University, 525 N. Wolfe Street, Baltimore, MD 21205, USA;Department of Occupational Therapy, University of Florida, 2107A Health Professions Building, Box 100164, Gainesville, FL 32610-0164, USA;Department of Health Outcomes and Policy, University of Florida, Box 100177, Gainesville, FL 32610-0177, USA

关键词: Nonpharmacologic;    Veteran;    Activity;    Caregiving;    Caregivers;    Behaviors;    Dementia;    Alzheimer’s;   

Others  :  856814
DOI  :  10.1186/1471-2318-13-96

 received in 2013-08-02, accepted in 2013-08-28,  发布年份 2013

【 摘 要 】

Background

Behavioral symptoms accompanying dementia are associated with increased health care costs, reduced quality of life and daily functioning, heightened family caregiver burden, and nursing home placement. Standard care typically involves pharmacologic agents, but these are, at best, modestly effective, carry serious risks, including mortality, and do not address behavioral symptoms families consider most distressful and which may prompt nursing home placement. Given dementia’s devastating effects and the absence of an imminent cure, the Veterans Administration has supported the development and testing of new approaches to manage challenging behaviors at home.

Methods/Design

The Tailored Activity Program – Veterans Administration is a Phase III efficacy trial designed to reduce behavioral symptoms in Veterans with dementia living with their caregivers in the community. The study uses a randomized two-group parallel design with 160 diverse Veterans and caregivers. The experimental group receives a transformative patient-centric intervention designed to reduce the burden of behavioral symptoms in Veterans with dementia. An occupational therapist conducts an assessment to identify a Veteran’s preserved capabilities, deficit areas, previous roles, habits, and interests to develop activities tailored to the Veteran. Family caregivers are then trained to incorporate activities into daily care. The attention-control group receives bi-monthly telephone contact where education on topics relevant to dementia is provided to caregivers. Key outcomes include reduced frequency and severity of behavioral symptoms using the 12-item Neuropsychiatric Inventory (primary endpoint), reduced caregiver burden, enhanced skill acquisition, efficacy using activities, and time spent providing care at 4 months; and long-term effects (8 months) on the Veteran’s quality of life and frequency and severity of behavioral symptoms, and caregiver use of activities. The programs’ impact of Veterans Administration cost is also examined. Study precision will be increased through face-to-face research team trainings with procedural manuals and review of audio-taped interviews and intervention sessions.

Discussion

The Tailored Activity Program – Veterans Administration is designed to improve the quality of life of Veterans with dementia and lessen the burden of care on caregivers. Activities are tailored to reflect the Veteran’s preserved capabilities and interests to enhance active engagement, while not taxing areas of cognition that are most impaired.

Trial registration

ClinicalTrials.gov, NCT01357564

【 授权许可】

   
2013 Gitlin et al.; licensee BioMed Central Ltd.

【 图 表 】

【 参考文献 】

• [1]Alzheimers Association: 2013 Alzheimer’s disease facts and figures. Retrieved May 28, 2013, from http://www.alz.org/documents_custom/2013_facts_figures_fact_sheet.pdf webcite
• [2]Krishnan LL, Petersen NJ, Snow AL, et al.: Prevalence of dementia among veterans affairs medical care system users. Dement Geriatr Cogn Disord 2005, 20(4):245-253.
• [3]Gitlin L, Kales H, Lyketsos C: Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012, 308(19):2020-2029.
• [4]Savva GM, Zaccai J, Matthews FE, et al.: Prevalence, correlates and course of behavioural and psychological symptoms of dementia in the population. Br J Psychiatry 2009, 194(3):212-219.
• [5]Beeri MS, et al.: The cost of behavioral and psychological symptoms of dementia (BPSD) in community dwelling Alzheimer’s disease patients. Int J Geriatr Psychiatry 2002, 17:403-408.
• [6]Salzman C, Jeste DV, Meyer RE, et al.: Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology, and policy. J Clin Psychiatry 2008, 69(6):889-898.
• [7]Schneider LS, Tariot PN, Dagerman KS, et al.: Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med 2006, 35:1525-1538.
• [8]Brooker DJ, Woolley RJ, Lee D: Enriching opportunities for people living with dementia in nursing homes: an evaluation of a multi-level activity-based model of care. Aging Ment Health 2007, 11(4):361-370.
• [9]Gitlin L, Hodgson N, Jutkowitz E, Pizzi L: The cost-effectiveness of a nonpharmacologic intervention for individuals with dementia and family caregivers: the tailored activity program. Am J Geriatr Psychiatry, Spec Issue Depress Dement Care 2010, 18(6):510-519.
• [10]Cohen-Mansfield J, Marx MS, Dakheel-Ali M, Regier NG, Thein K, Freedman L: Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli? J Am Geriatr Soc 2010, 58(8):1459-1464.
• [11]Kolanowski A, Buettner L: Prescribing activities that engage passive residents. An innovative method. J Gerontol Nurs 2008, 34(1):13-18.
• [12]Evans L: Recognizing the 75th anniversary of the establishment of the veterans administration. House of representatives. Washington, D.C.: U.S. Government Printing Office; 2005.
• [13]Oliver A: The veterans health administration: an American success story? Milbank Q 2007, 85(1):5-35.
• [14]United States Office of Personnel Management: FedScope: federal human resources data. 2012. [Data file]. Retrieved from: http://www.fedscope.opm.gov/ibmcognos/cgi-bin/cognosisapi.dll webcite
• [15]McGinnis KA, Schultz R, Stone RA, Klinger J, Mercurio R: Concordance of rance or ethnicity of interventionists and caregivers of dementia patients: relationship to attrition and treatment outcomes in the REACH study. The Gerontologist 2006, 46(4):449-455.
• [16]Gitlin LN, Winter L, Earland TV, Herge EA, Chernett NL, Piersol CV, Burke JP: The tailored activity program to reduce behavioral symptoms in individuals with dementia: feasibility, acceptability, and replication potential. Gerontologist, Pract Concepts 2009, 49(3):428-439.
• [17]Jutkowitz E, Gitlin LN, Pizzi L: Evaluating willingness to pay thresholds for dementia caregiving interventions: application to the tailored activity program. Value Health 2010, 13(6):720-725.
• [18]Mahoney DF, Jones RN, Coon D, Mendelsohn AB, Gitlin LN, Ory M: The caregiver vigilance scale: application and validation in the resources for enhancing Alzheimer's caregiver (REACH) project. Am J Alzheimer's Dis Dement 2003, 18:39-48.
• [19]Phibbs CS BP, Fan A, Harden C, King SS, Scott JY: Research guide to decision support system national cost extracts. Menlo Park, CA: Health Economics Resource Center of Health Services R&D Services, Department of Veterans Affairs; 2010.
• [20]Barnett PG: Review of methods to determine VA health care costs. Med Care 1999, 37(4 Suppl Va):AS9-AS17.
• [21]Smith MW, Barnett PG: Direct measurement of health care costs. Med Care Res Rev 2003, 60(3 Suppl):74S-91S.
• [22]Chou SL, Lamoureux E, et al.: Methods for measuring personal costs associated with vision impairment. Ophthalmic Epidemiol 2006, 13(6):355-363.
• [23]Tambour M, Zethraeus N, et al.: A note on confidence intervals in cost-effectiveness analysis. Int J Technol Assess Health Care 1998, 14(3):467-471.