An evaluation of the effectiveness of a case-specific approach to challenging behaviour associated with dementia

Abstract

Results confirm those of other studies which have used multifaceted interventions tailored to the unique needs of each case. They compare favourably with results from trials of standardized psycho-pharmacological or psychosocial approaches. More trials are needed, necessarily involving further development of robust methodologies which reflect the case-specific nature of challenging behaviour associated with dementia.

An RCT to evaluate the utility of a clinical protocol for staff in the management of behavioral and psychological symptoms of dementia in residential aged-care settings

“…In the main, these case-specific studies have had more rigorous methodology than trials of standardized psychosocial interventions, and have produced superior results. These include reductions in frequency and perceived severity of the target behavior and GP call outs (Davison et al, 2006); reductions in anti-psychotic use (Fossey et al, 2006); reductions in agitated behavior and increases in observed participant pleasure (Cohen-Mansfield, Libin, & Marx, 2007); and reductions in BPSD frequency and perceived severity, staff stress, hospitalizations, anti-psychotic use, and drug side effects (Bird, Llewellyn Jones, & Korten, 2009;Bird, Llewellyn Jones, Korten, & Smithers, 2007). Brechen, Murphy, James, and Codner (2013) highlight the need to examine psychological interventions as alternatives to anti-psychotic medication for the treatment of BPSD.…”

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

“…However, case specificity 62 to include examination of relevant biopsychosocial interventions for the person as well as good attention to the needs of the caregiving system still appears to be the way forward for the management of CB in dementia. A functional analysis approach to interventions for CB in dementia care provides a framework for assessment and targeting of case-specific formulaic interventions.…”

“…15 An independent assessment of improvements in dementia care since 2009 commissioned by the Department of Health, outlines priorities for action in the final year of the 'Prime Minister's Challenge on Dementia', including the need for psychosocial and other alternatives to pharmacological management of CB, to guide commissioners or providers (see Knapp et al pp. 3,62). 302 Our programme of empirically informed knowledge about practices and recommendations for post-diagnostic service improvements that are urgently required for the management of CB in dementia care will go some way to address this priority.…”

“…Changes in behaviour or family carer or staff distress are more likely to occur in programmes that are more case or client specific, that is, education that is person centred or more explicitly links interventions to the specific environment. 60 Examples of outcomes for people with dementia living in residential care have been reductions in frequency and perceived severity of the target behaviour and general practitioner (GP) call-outs, 50 reductions in antipsychotic use, 27 reductions in agitated behaviour and increases in observed participant pleasure, 61 reductions in behaviour frequency and perceived severity, hospitalisations, antipsychotic use, and drug side effects; 26,62 and for staff, reductions in stress and short-term improvements in the perception of how challenging staff found the behaviour. 63 Systematic interventions of this type, targeting a variety of outcomes within family care settings, are less common, but they can be found, including within NHS settings in England, where they have demonstrated reductions in CB and improvements in carer mental health.…”

“…12 This biopsychosocial approach to assessment, analysis and the testing of interventions for CB in dementia, which we describe as functional analysis-based interventions, 82 is also known as individualised formulation-led interventions for CB in dementia care. 97,186,303,304 They are usually algorithmic to enhance case specificity 62 and are delivered by trained practitioners who have access to knowledge and expertise from other professionals such as psychiatrists, geriatricians and experienced psychologists. 15,26,27,50,97 A trained therapist is usually required for such an intervention, 82 as a key skill in working in this area is the ability to be flexible and have the capability to alter care plans as new needs arise, meaning that the process remains iterative but the functional analytical skills remain at the core of the plan.…”