agitaon/aggression in elderly: what works · scores • cohen-mansﬁeld agita6on inventory (cmai):...

Agita&on/AggressioninElderly:Whatworks

G.MichaelAllanProfessor,DeptofFamily,UofA.

Director,Evidence&CPDProgram,ACFP

Background:Agita6oninDemen6a•  Demen&acan>agita&onandviolentbehavior–  Alsocandeliriumandassociateproblems.

•  Hardtomanage.•  Considerundiagnosedpain•  Someotherkeypointsfromtheliterature,…

Scores•  Cohen-MansfieldAgita6onInventory(CMAI):Assessesthefrequencyofmanifesta&onsofagitatedbehaviorsinelderlypeople.–  29measuresagita&onbehaviour,score1(never)to7(several/hour)

–  Scoreis29-203.Higherworse.– NoMCID.Scoreof≥39=agita&on.*

•  BriefPsychiatricRa6ngScale(BPRS):Notspecificallyagita&on.–  18measuresbehaviour,score1(notpresent)to7(extremelysevere)

–  Scoreis18-126.Higherworse.– Mildlyill≥31,moderate≥41,markedly≥53– MCID=25%improvement

Scores•  NeuropsychiatricInventory(NPI):measuresphysical&verbalaggression,hallucinatorybehaviour,&abnormalthoughtcontent–  12measuresbehaviour,Frequency/severity/disrup&onscore0-12

–  Scores:0-144,higherworse.– Mild<20,moderate20-50,severe≥50– MCID4-9points,

•  Behave-AD:Behaviouralsymptomsofdemen&a,–  25behaviours,rated0-3–  Score0-75,higherworse.

•  ClinicalGlobalImpressionScale:7-pointscalewithscoresrangingfrom1(noaggressivebehaviour)to7(severelyaggressivebehaviour).–  CanbeusedaClinicalGlobalImpressionofChange.MCID=1

Whathappenswhenyougiveplacebo?

Baseline 3weeks 9weeksNeurobehavioralRa&ngScaleagita&onsubscale(NBRS-A)

7.8(3.0) 5.7(3.1) 5.4(3.2)

Cohen-MansfieldAgita&onInventory(CMAI)

28.7(6.7) 26.9(6.7) 26.7(7.4)

NeuropsychiatricInventoryAgita&on/Aggressiondomain(NPIA/A)

8.0(2.4) 4.9(3.1) 4.9(3.8)

NeuropsychiatricInventory(NPI)-Total

37.3(17.7) 26.1(16.1) 28.4(22.1)

ClinicalGlobalImpressionofChange(CGI-C)

n/a 29%“improved”

26%“improved”

MentalStatusExam(MSE) 14.4 14.9 15.7

IntPsychogeriatr.2015;27(12):2059–67.

•  Biggesteffectinfirstweeks.•  Also,moreseverescoresgotgreaterbenefit.

10yearsago,Whatdidweknow?•  AtypicalAn&-psycho&cforBehavioralproblemsinDemen&a1

–  Meaneffectsizefor7placebo-controlledstudies:•  0.45(95%CI=0.16-0.74)foratypicalan&psycho&cs,•  0.32(95%CI=0.10-0.53)forplacebo.(Nodifference)

•  CochraneMeta-analysis2(16placebocontrolledtrials,9sufficientdataformeta-analysis,5fullpublishedinpeerreviewedjournals)1.  Therewasasignificantimprovementinaggressionwithrisperidoneandolanzapinetreatment

comparedtoplacebo.2.  Therewasasignificantimprovementinpsychosisamongstrisperidonetreatedpa&ents.3.  Risperidoneandolanzpainetreatedpa&entshadasignificantlyhigherincidenceofserious

adversecerebrovascularevents(includingstroke),extra-pyramidalsideeffectsandotherimportantadverseoutcomes.

4.  Therewasasignificantincreaseindrop-outsinrisperidone(2mg)andolanzapine(5-10mg)treatedpa&ents.

5.  Thedatawereinsufficienttoexamineimpactuponcogni&vefunc&on.

1) Psychother Psychosom. 2007;76(4):213-8. 2) Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003476.

An6-Psycho6cs:Benefits

•  Systema&creview:16RCTs(5050pt)– median10weeks(range6-26)

•  Scorechanges(overplacebo):– CMAI,meandiff=−1.84,(-0.67to-3.01)– NPI,meandiff=−2.81(-1.28to−4.35)– BPRS,meandiff=−1.58(-0.65to−2.52)– CGI-C,meandiff=−0.32,(-0.20to−0.44)

•  Allthesechangesaresmall.

JAlzheimersDis.2014;42(3):915-37.

An&-Psycho&cs:Benefits,OtherReviews

•  Cochrane:1Over10-13weeks,–  RisperidoneCMAI,MeanDiff=-1.17[-0.32,-2.02]– OlanzapineNPI-NH,MeanDiff-2.46[-5.53,0.61]

•  Que&apine:25RCTs(1118pts),6-10weeks– NPI,MeanDiff=3.05(-0.01to-6.10)

–  CGI-C,MeanDiff=-0.31(-0.08to-0.54)•  Haloperidol:35RCTs,3-16weeks.

– Anyagita&onSMD=-0.12[-0.33to0.08],notsign.– AnyaggressionSMD=-0.31(-0.13to-0.49),sign

•  Clinicalmeaningunknown(likelysmall)

1)Cochrane2006;1:CD003476.2)NZMedJ.2011;124(1336):39-50.3)Cochrane2002;2:CD002852.

Buthowmanyactuallygetbever?

Drug 50%improvementinthisoutcome

OddsRa6o Treatmentrate

PlaceboRate

NNT

Aripipazole NPI 1.50(1.14–1.99) 48.5% 38.2% 10Risperidone BEHAVE-AD 1.79(1.37–2.33) 46.3% 32.6% 8Risperidone CGI–C(much/very

muchimproved)2.01(1.49-2.72) 64.7% 47.8% 6

Haloperidol* CGI-C(improved) 1.50(0.88–2.55) 67.4% 59% ns

•  Systema&cReview:16RCTs(5110pts),8-12weeks.

AmJGeriatrPsychiatry2006;14:191-210.*Cochrane2002;2:CD002852.

•  Whilescalesdonotseemtochangemeaningfully,around50%ofpa&entswillgetameaningfulimprovement.

•  Furthermore,1in6to1in10willdomeaningfullybeverthanplacebo.

WhataretheAdverseEvents?Outcome RCTs OddsRa6o Treatment

RatePlaceboRate

NNH

Mortality 14 1.52(1.06-2.18) 3.6% 2.3% 77Cerebrovascular 9 2.50(1.36-4.60) 2.1% 0.9% 84Extrapyramidal 12 1.74(1.41-2.41) 15.2% 8.6% 16Somnolence 11 2.95(2.33-3.75) 17.0% 7.2% 11GaitAbnormality 7 3.35(2.06-5.46) 6.9% 1.7% 20Agita6on 9 0.80(0.65-0.98) 10.6% 13.3% 38NNTPeripheralEdema2 8 1.99(1.20–3.30) 9% 4% 20UTI2 11 1.51(1.07-2.12) 13% 9.4% 28MSE2 7 MeanDifference Worseby0.73(0.38to1.09)

JAlzheimersDis.2014;42(3):915-37.2)AmJGeriatrPsychiatry2006;14:191-210.

AdverseEvents,Con&nued

•  WithdrawalduetoAdverseEvents– Risperidone1mg:1OR1.43[1.01,2.03].11.8%vs9.2%,NNH39

– Olanzapine5-10mg:1OR3.34[1.69,6.59].11.5%vs3.7%,NNH13

– Haloperidol:2OR2.52[1.22,5.21],17%vs7.2%,NNH11

•  Bovom-Line:Lotsofharms,andsomeveryconcerningones.

1)Cochrane2006;1:CD003476.2)Cochrane2002;2:CD002852.

Arean&-psycho&cscosteffec&ve?

•  Bovom-line:An&-psycho&csarenotcosteffec&vebecausetheyhadlivleeffect(overplacebo)butweremorecostly.

ArchGenPsychiatry.2007;64(11):1259-1268

StoppingAn6-psycho6cs•  DART-AD:1RCT,165pa&ents,meanage85,76%female,long-termcare– Withdrawan&psycho&c(placebo)orcon&nue

•  Outcomes:Behavior,2Nonestatsign.– Mortality:at2years,71%con&nuedan&-psycho&cvs46%placebo,(Diff=25%,NNT4)

•  SysReview:9trials.Nodiffbehaviour3except1RCT4–  110ptswithverifiedgoodresponseonRisperidone1mg,withdrawnayer4-8months:

•  30%worseningofNPI:60%placebovs33%risperidone,NNH4•  BoXom-Line:Bevertowithdrawalsoonunlessyouaresuretheyhavehadagoodresponseandlikelyneedit.

1) Lancet Neurol 2009; 8:151–57. 2) PLoS Med 5(4): e76.doi:10.1371/journal.pmed.0050076 3) Cochrane 2013;3: CD007726. 4) N Engl J Med 2012;367:1497-507.

SummingUpBENEFITS1.  Therewasasta&s&callysignificantimprovementinagita&on/aggression

behaviourscaleswithplacebo.2.  Therewasasta&s&callysignificantbutsmallimprovementinagita&on/

aggressionbehaviourscalesfroman&-psycho&cs,comparedtoplacebo.3. Whenlookingatnumberswithmeaningfulchange,thatwilloccurin~50%of

pa&entsonan&-psycho&c,thatis~10-15%morethanplacebo.HARMS1.  An&psycho&cshavelotsofharms,andsomeareveryserious(strokeand

Mortality),withNNHof~80(in3months).2.  Eventhoughagitatedanddemen&a,Adverseeventswills&llcause1in10to1

in40towithdrawal(overplacebo)3.  An&-psycho&csreduceMSEby0.73(in3months)Withdrawal1. Withdrawalofan&-psycho&cswilldelayonedeathforevery4withdrawn,

withoutworseningbehaviourinmostcases2.  Behaviourmayworsen(foronein4overplacebo)incasesinwhichbenefit

froman&-psycho&cisverified.

Benzodiazepines•  8RCTs,benzodiazepinevsan&-psycho&cs,placebosorother

drugs:–  DiazepamvsThioridazine(40ptsx4wks):Thioridazinesta&s&callybever1

•  Nursesra&ngofimprovement:70%Thioridazinevs15%Diazepam.NNT=2.–  OxazepamvsHaloperidolvsDiphenhydramine(59ptsx8wks):2Nosta&s&caldifferencebutOxazepamworsebehavioralscores.

–  AlprazolamvsHaloperidol(48ptsx12wks):3Bothtreatmentsworsethanbaselinebutnosta&s&caldifference.

–  LorazepamvsOlanzapinevsplacebo(272ptsx1d):4Lorazepam1mgsimilartoOlanzapine(5mgand2.5mg),andallbeverthanplacebo.

•  40%improvedPANSS-EC(measuresagita&on)at2hours:Lorazepam72%,Olanzapine62-67%,placebo37%.LorazepamNNT=3.

1)SouthMedJ.1975;68:719-724.2)AmJPsychiatry.1990;147:1640-5.3)JAmGeriatrSoc.1998;46:620-5.4)Neuropsychopharmacology.2002;26:494-504.5)ClinTher.1984;6:546-59.6)DisNervSyst1965;26:591-5.7)Geriatrics.1965;20:739-46.8)IntClinPsychopharmacol1991;6:141-6.

Benzodiazepines•  8RCTs,con&nued:

–  DiazepamvsThioridazinevsplacebo(610ptsx4wks):5DiazepamworsethanThioridazinebutbeverthanplaceboonsomescales.

•  1pointimprovementononeanxietyscale:65%Diazepam,77%Thioridazine,42%placebo.

–  Oxazepamvsplacebo(100pts):6Oxazepambever.•  “Moderateimprovement”clinicalresponse:OxazepamNNT=2.

–  Oxazepamvsplacebo(94ptsx8wks):7Oxazepambever.•  “Slightimprovement”orbeverclinicalresponse:OxazepamNNT=5.

–  TemazepamvsLorazepam(11ptsx1d):8Nosta&s&caldifference•  Harms:Poorrepor&ngofharms.

–  Mild-moderateseda&on:Lorazepam(10.3%)vs.Olanzapine5mg(4.2%)vsOlanzapine2.5mg(3%),placebo(3%).4

1)SouthMedJ.1975;68:719-724.2)AmJPsychiatry.1990;147:1640-5.3)JAmGeriatrSoc.1998;46:620-5.4)Neuropsychopharmacology.2002;26:494-504.5)ClinTher.1984;6:546-59.6)DisNervSyst1965;26:591-5.7)Geriatrics.1965;20:739-46.8)IntClinPsychopharmacol1991;6:141-6.

Benzodiazepines•  Guidelinesforagita&onindemen&avary:9

–  Some(exampleBri&shColumbia)discouragebenzodiazepinesbecauseadverseevents

–  Others(exampleAmericanPsychiatricAssocia&onandNICE-UK)suggestconsideringshort-ac&ngbenzodiazepinesasneededforinfrequentagita&on.

•  BoXom-Line:Manytrialsareold,mostareshortand/orsmall,andtheresultsareinconsistent.Benzodiazepinesappear,atbest,equivalenttoan&psycho&csinreducingagita&onintheshort-term,butsuperiortoplacebo.Ifused,theyshouldbestoppedassoonaspossibleduetopoten&alharms.

McIntoshB,ClarkM,SpryC.Ovawa:CanadianAgencyforDrugsandTechnologiesinHealth;2011.Availablefrom:hvp://www.cadth.ca/media/pdf/M0022_Benzodiazepines_in_the_Elderly_L3_e.pdf

WhataboutAn6-Cholinesterases?

•  Meta-analysisofbehavioralandpsychologicalsymptomsofDemen&a:12studies(9withenoughdataforanalysis)

•  ChEIsasaclasshadabeneficialeffectsonreducingBPSD:–  BPSD=BehavioralandPsychiatricSymptomsofDemen&a–  SMDof-0.10(CI;-0.18,-0.01)and–  WMDof-1.38neuropsychiatryinventorypoint(CI;-2.30,-0.46).–  InmildADpa&ents,theWMDwas-1.92(CI;-3.18,-0.66);–  InsevereADpa&ents,theWMDwas-0.06(CI;-2.12,+0.57).

•  Bottom-Line: “ClinicalRelevanceofthiseffectremainsunclear”

Clin Interv Aging. 2008;3(4):719-28.

The “other” med: Memantine •  Mostly Moderate - Severe Dementia

–  ADCS -ADL score, Severe impairment battery, Functional assessment Staging, Clinician Impression of Change (CIBIC): All 0-4% change

–  Possibly <agitation (NNT= 63) - if already on –  Well Tolerated (no diff in drop-out due to AE) –  Other studies use SMD statistic & can’t interpret.3

•  Bottom-Line: Effects are small & inconsistent.

Cochrane 2006;(2):CD003154. Health Technol Assess 2012;16(21). 3) PLoS ONE 10(4): e0123289.

OtherMedica&ons:An&depressants

•  SSRI:19RCTs(692pa&ents)– VsPlacebo:CMAI,MeanDiff-0.89[-0.57,-1.22]

•  NoincreasedWithdrawalforAE.

– VsHaldol:CMAI,MeanDiff,4.66[-3.58,12.90],favorsHaldol

•  Trazodone:22RCTs(180ptsbutnotpooled):– VsPlacebo:Noeffect– VsHaldol:1CMAI,MeanDiff,3.28[-3.28,9.85],favorsTrazodone

1)Cochrane2011;2:CD008191.2)Cochrane:2004;3:CD004990.

OtherMedica&ons:Valproate

•  Valproate:5RCTs(412pts)x6wks– Outcomes

•  CMAIMeanDiff:-2.20[-6.38,1.99],Nodiff•  BPRSMeanDiff:0.23[-2.14,2.60],Nodiff•  AnyadverseeventOR1.99(1.29-3.08),75%vs60%(NNH7)

•  BoXom-Line:SSRITrazodoneandValproatelikelyhavelivletonoreliableeffect.

Cochrane2009;3:CD003945.

Rememberpain•  RCTofassessingforpain

–  920Nursinghomeresidents–  420hadmoderate-severedemen&awithbehaviouraldisturbance(352included)

–  201(57%)assessedashavingpain(onthemobilisa&on-observa&on-behaviour-intensity-demen&a-2painscale)

•  Outcomes–  68%neededonlyacetaminophen,32%gotbuprenorphinepatch,pregabaline,&rarelymorphine).

–  CMAI:−7.0(−3.7to−10.3).Othersimprovedaswell.•  Bovom-Line:Rememberagita&onmaybefrompainandaslivleasacetaminophenmayhelpmeaningfully.

BMJ2011;343:d4065

SummingUp

•  Noneoftheothermedicines(benzodiazepines,SSRI,trazodone,cholinesteraseinhibitors,valproate)workwell.

•  Maybebenzo’sasaback-up,buttheymaywellworklessthanan&-psycho&csandthereisnoevidencetheyaresafer.

•  RememberPainasapossiblecauseofagita&on.

Non-Pharmaceu6calInterven6ons1  Shiatsu&Acupressure2  Aromatherapy3  Massagetherapy4  Light(Bright)Therapy5  SensoryGarden&Hor&cultural

Ac&vi&es6  Music&DanceTherapy7  DanceTherapy8  SnoezelenMul&sensory

s&mula&ontherapy9  Transcutaneouselectricalnerve

s&mula&on.10  Exercisetherapy11  Animal-AssistedTherapy12  Combina&onofTherapies

13  Cogni&veS&mula&on14  Reminiscencetherapy15  Valida&onTherapy16  SimulatedPresencetherapy17  BehavioralManagement18  FamilycareSupport19  AssistedLivingSupport20  Residen&alSupport21  Animal-AssistedTherapy22  SpecialCareUnits23  Demen&aCareMap24  Pa&ent-CentredCare25  SimulatedPresence26  Manyvaria+onsonthemesabove

AbrahaI,etal.BMJOpen2017;7:e012759.Livingstonetal.HealthTechnolAssess2014;18(39).

Non-Pharmaceu&cals:SomethatMayWork

1.  Ac&vi&es(grouporindividual):e.g.cooking

2.  MusicTherapy(protocol)3.  SensoryInterven&ons4.  Workingthrupaid

caregiversforperson-centredcare&Communica&onSkills

5.  Demen&aCareMap6.  BehavioralManagement

Mostareunclearasinadequateevidence:•  Example:PetTherapy

SomeareDon’tWork•  ExampleAromatherapy.

Livingstonetal.HealthTechnolAssess2014;18(39).

Ineffec&veNon-Pharmaceu&cal:AromatherapyExample

•  Earlyresearch:1pooledin“sensory”gavelargechange(Standardmeandiff=1.07)– Pooledtoomanythingsandstatspoorlyreported

•  Cochrane:27RCTs(428pts),mostlylavender– 5RCTsused3agita&onscales,resultsequivocal.– AdverseEvents:equalbetweengroups.

•  HTA:36RCTs(276pts)– goodevidencefromhigh-qualitystudies:noeffect.

•  BoXom-Line:Aromatherapydoesnotwork!1)AgingMentHealth.2009;13:512-202)Cochrane:2014;2:CD003150.3)Livingston.HealthTechnolAssess2014;18(39).

InadequateNonpharmaceu&cal:ExamplePet-Therapy

PetTherapy•  HTA:3studies(non-

randomized)with26par&cipantstotal!–  Nosta&s&calchangesin

agita&onetc.•  10studies:3case-controlor

7&me-seriesanalysis–  Maybehelpfulbutunclear

•  Bovom-Line:Inadequateresearch.

SimulatedPresence•  SimulatedPresence•  3RCTs(144pts)

–  Researchsoup(Twowere4arms&onewasthree;twousedcross-over,numberssmall,varyingmeasuressomeposi&veatsomepointsversussomecomparators).

•  Bovom-Line:Wedon’tknow?

Livingston.HealthTechnolAssess2014;18(39).AbrahaI,etal.BMJOpen2017;7:e012759


Non-Pharmaceu6cal:Thingsthatlikelywork

EffectSize Studies(pa6ents)

Ac&vi&es(grouporindividual):e.g.cooking

-0.8to-0.6 8RCT(587)+2lower

MusicTherapy(protocol) -0.8to-0.5 6RCT(335)+4lower

SensoryInterven&ons -1.3to-0.6 7RCT(508)+6lower

WorkingthrupaidcaregiversforPerson-CentredCare&Communica&onSkills

-1.8to-0.3 7RCT(952)+1lower

Demen&aCareMap -1.4to-0.6 2RCTs(226)

BehavioralManagement Notcalculated 1RCT(31)

•  Lotsofoverlaps.–  Exampleac&vi&esorsensorymighthavemusicaspartthem.–  ExampleDCMandPCCoyenoverlapinsame

Livingston.HealthTechnolAssess2014;18(39).

Non-Pharmaceu&cal:Ac&vi&es•  HTA:8RCT(587)

–  Es&matedEffect:SMD:-0.6to-0.8•  TheirSummary

–  Overall,ac&vi&esincarehomesreduceemergentagita&onanddecreasesymptoma&cagita&onincarehomesduringthe&metheyareinplace.

–  Individualisingac&vi&esdoesnotappeartomakesignificantaddi&onalreduc&onsinagita&on.

–  Thereisnoevidenceforthosewhoareseverelyagitatedorwhoarenotincarehomes.

•  Bovom-Line:Doesnotpersistayerinterven&onsregularuse(1-4weekslater),behaviourreturns.Realuncertaintyifthereisaneffect.


Non-Pharmaceu&cal:Music

•  HTA:6RCTs(335pts)–  Incarehomes,musictherapyby

protocoliseffec&veforemergentagita&onanddecreasingsymptoma&cagita&on,buthasnolong-termusefulnessinagita&on.

–  Thereisnoevidenceforpeoplewithsevereagita&on.Thereisminimalevidenceoutsidecarehomes.

•  Cochrane:16RCTs(620pa&ents)•  Findings:

–  emo&onalwell-being&qualityoflife(6RCTs,181pts):SMD0.32(-0.08to0.71)

–  overallbehaviourproblems(6RCTs,209pts):SMD−0.20(−0.56to0.17)

–  agita&onoraggression(12RCTs,515pts):SMD−0.08(−0.29to0.14).

Livingston.HealthTechnolAssess2014;18(39).Cochrane2017;5:CD003477.FrontPsychol.2017May16;8:742.AgeingResRev.2017May;35:1-11.

5ormoresessionswithawarm-up(familiarsong),thenlistening,thenjoiningin.Oyen2&mesperweekfor6weeksormore

BoXom-Line:Themostunbiasedworkraisesdoubtwhethermusictherapycanimproveagita&onindemen&a.

Twoothersmoreposi&ve.

Non-Pharmaceu&cal:Sensory•  HTA:7RCT(508pts):Therapeu&ctouch,massage,acupressure,

snoezelen.bathingwithmusic,etc.–  Es&matedeffect:SMD-0.6to-1.3

•  TheirSummary–  Sensoryinterven&onssignificantlyimprovedemergentagita&on,symptoma&cagita&on,andsevereagita&onduringthe&metheinterven&ontookplace.

–  Therapeu&ctouchhasnoaddedadvantages.–  Thereisinsufficientevidenceaboutlong-termeffectsorinse�ngsoutsidecarehomes.

•  Cochrane:7possibleRCTs,butonly2used(butdone2006):–  Toolivleevidencetosay.

•  BoXom-Line:Maybebutifaneffect,notclearforhowlong.

Livingston.HealthTechnolAssess2014;18(39).Cochrane2006;4:CD004989.

Pa&ent-CentredCare•  HTA:7RCT(952)

–  Es&matedEffect:SMD-0.3to-1.8•  Oneofthefewwithconsistentevidenceofbenefit,oyenfrom

higherqualitystudies,andpersistenceofeffect(evenupto20weeks)

•  TheirSummary–  Thereisconvincingevidencethattrainingpaidcaregiversin

communica&onorperson-centredcareskillsiseffec&veforsymptoma&candsevereagita&on,bothimmediatelyandupto6months,inthecarehomese�ng.

–  Thereispreliminaryevidencethatithelpstopreventemergentagita&on.–  Evidenceforse�ngsotherthancarehomesislimited.

•  BoXom-Line:Thislikelywork.ItistangledwithDemen&aCareMapsandCommunica&on/Behaviouralbutthecombina&onlikelyveryhelpful.


Demen&aCareMapping&Communica&on/BehaviouralManagement•  HTA:2RCTs(226)

–  Es&matedEffect:SMD-0.6to-1.4

•  TheirSummary–  ThereissomeevidencethatDCMiseffec&veimmediatelyandover4monthsforsevereagita&onincarehomes.

–  Thereislivleevidenceforemergentagita&onorsymptoma&cagita&on,orinotherse�ngs.

•  Bovom-line:Likelyworks

•  HTA:1RCT(31)•  TheirSummary:

–  Thereispreliminaryevidencethattrainingpaidcaregiversinbehaviouralmanagementandcommunica&onskillsiseffec&veinreducingagita&onsymptomsinassistedlivingse�ngsintheshortterm.

–  Thereisnoevidenceinthisse�ngforthelonger-termeffects.

•  Bovom-line:Likelyworks


ComplexToolswitheduca&on:Dotheyreducean&-psycho&cuse?

•  Bovom-Line:Theywork!

Study Follow-upMonths

Treatment Control FinalDifferenceBaseline>Finish Diff Baseline>Finish Diff

Avorn 6 29%>24% 5% 26%>25% 1% 4%Fossey 12 47%>23% 24% 50%>42% 8% 16%Schmidt 13 40%>33% 7.% 38%>35% 3% 4%Meador* 6 25>19 5.6d 26>26 0.2d 5.4d

•  Cochrane:4RCTs(69clustersof4337residents)–  Complexeduca&onal/training&mee&ngsforpsychosocialinterven&onstoreducean&-psycho&cuse

*Reportedasan&psycho&cuseper100Pa&entDays


Complex:SpecializedCareUnits

•  SpecializedCareUnits:featuresoftrainedstaffing,specialprogramming,amodifiedphysicalenvironment,andfamilyinvolvement

•  Cochrane:NoRCTsbut8observa&onal,at6months– NPI:4.3bevervsplacebobutothers(e.g.CMAI)notsta&s&calbever.

–  Likelyreduceusedofrestraints:OddsRa&o0.46[0.27,0.80],46%vs61%,NNT7

•  Bovom-Line:AsSCUincludealotofthefeaturesofcomplexinterven&ons,theyprovidesomebenefit.


SummingUp

•  Despitelotsofgreatideas,livlegoodevidencetosupportnon-drugmeasures

•  SimpleInterven&onswithpossiblebenefitincludeac&vi&es,musicandsensorys&mulus.Sadly,thereiss&llrealuncertaintyiftheseworkreliably.

•  ComplexInterven&onslikeDemen&aCareMapsandtrainedPa&ent-CentredCareworkbutarecomplexandrequirebroadersystemlevelcommitment.

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