TIME to reduce agitation in persons with dementia in nursing homes. A process evaluation of a complex intervention

Bjørn Lichtwarck, Janne Myhre, Geir Selbaek, Øyvind Kirkevold, Anne Marie Mork Rokstad, Jūratė Šaltytė Benth, Sverre Bergh, Bjørn Lichtwarck, Janne Myhre, Geir Selbaek, Øyvind Kirkevold, Anne Marie Mork Rokstad, Jūratė Šaltytė Benth, Sverre Bergh

Abstract

Background: The Targeted Intervention Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a three-month cluster randomised controlled trial demonstrated reduction in agitation in nursing home residents with dementia. To ease replication and future implementation, and to clarify possible causal mechanisms, we performed a process evaluation of the intervention based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance).

Methods: An exploratory and a quasi-experimental design with mixed methods were used. The RE-AIM dimensions were explored by questionnaires to 807 staff members and 46 leading ward nurses in both the intervention nursing homes (INH) and the control nursing homes (CNH), before the start of the trial (baseline), and six and 12 months later. These questionnaires assessed data regarding the reach, effectiveness (staff level) and adoption dimensions. To assess implementation, we used a checklist for performance of the main components in TIME and analysed the minutes from 84 case conferences in the INH. To explore adoption and maintenance, five focus group interviews with 32 participants from the staff in the INH were conducted three to 6 months after the end of the trial.

Results: Reach: On average 61% (SD 22) of the staff in each ward in the INH attended the training sessions. Effectiveness at staff level: There were no between-group differences throughout the study period for attitudes towards dementia, perceived competence or perception of mastery and social interaction. Adoption: 16 of the 17 INH completed the intervention.

Implementation: 75% or more of the components of TIME were performed for 91% of the included residents. Maintenance: Most of the nursing homes used TIME three to 6 months after the end of the trial. An easy to grasp model and an engaged leadership facilitated the intervention and maintenance.

Conclusions: A high degree of reach, adoption, implementation and maintenance contributed to the effectiveness of TIME at resident level. One other causal assumption of the effectiveness of TIME is the development in the staff of a new, shared and situated knowledge about each individual resident, not reflected by measurements in general knowledge and attitudes.

Trial registration: The trial was registered January 6, 2016 with ClinicalTrials.gov ( NCT02655003 ).

Keywords: BPSD; Case conferences; Complex interventions; Dementia; Implementation; Neuropsychiatric symptoms; Non-pharmacological interventions; Process evaluation; RE-AIM.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Documentary analysis of minutes from 84 case conferences. Notes: SMART, Specific, Measurable, Actual, Realistic, Time framed

References

    1. Selbaek G, Engedal K, Benth JS, Bergh S. The course of neuropsychiatric symptoms in nursing-home patients with dementia over a 53-month follow-up period. Int Psychogeriatr. 2014;26(1):81–91. doi: 10.1017/S1041610213001609.
    1. Selbaek G, Engedal K, Bergh S. The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review. J Am Med Dir Assoc. 2013;14(3):161–169. doi: 10.1016/j.jamda.2012.09.027.
    1. Wetzels RB, Zuidema SU, de Jonghe JF, Verhey FR, Koopmans RT. Course of neuropsychiatric symptoms in residents with dementia in nursing homes over 2-year period. Am J Geriatr Psychiatry. 2010;18(12):1054–1065. doi: 10.1097/JGP.0b013e3181f60fa1.
    1. Cummings J, Mintzer J, Brodaty H, Sano M, Banerjee S, Devanand DP, et al. Agitation in cognitive disorders: international psychogeriatric association provisional consensus clinical and research definition. Int Psychogeriatr. 2015;27(1):7–17. doi: 10.1017/S1041610214001963.
    1. Brodaty H, Connors MH, Xu J, Woodward M, Ames D. Predictors of institutionalization in dementia: a three year longitudinal study. J Alzheimers Dis. 2014;40(1):221–226. doi: 10.3233/JAD-131850.
    1. Peters ME, Schwartz S, Han D, Rabins PV, Steinberg M, Tschanz JT, et al. Neuropsychiatric symptoms as predictors of progression to severe Alzheimer's dementia and death: the Cache County dementia progression study. Am J Psychiatry. 2015;172(5):460–465. doi: 10.1176/appi.ajp.2014.14040480.
    1. Zeller A, Hahn S, Needham I, Kok G, Dassen T, Halfens RJ. Aggressive behavior of nursing home residents toward caregivers: a systematic literature review. Geriatr Nurs. 2009;30(3):174–187. doi: 10.1016/j.gerinurse.2008.09.002.
    1. Wang J, Yu JT, Wang HF, Meng XF, Wang C, Tan CC, et al. Pharmacological treatment of neuropsychiatric symptoms in Alzheimer's disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2015;86(1):101–109. doi: 10.1136/jnnp-2014-308112.
    1. Kales HC, Gitlin LN, Lyketsos CG. Detroit expert panel on a, Management of Neuropsychiatric Symptoms of D. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014;62(4):762–769. doi: 10.1111/jgs.12730.
    1. Brasure M, Jutkowitz E, Fuchs E, Nelson VA, Kane RA, Shippee T, et al. AHRQ comparative effectiveness reviews. Rockville (MD): Agency for Healthcare Research and Quality: US; 2016.
    1. Helsedirektoratet. Nasjonal faglig retningslinje om demens (Norwegian National Guideline on Dementia) Oslo: Helsedirektoratet (The Norwegian Directorate of Health); 2017 [updated 2017.10.07. Available from: . Accessed 8 Mar 2019.
    1. Livingston G, Kelly L, Lewis-Holmes E, Baio G, Morris S, Patel N, et al. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. Br J Psychiatry. 2014;205(6):436–442. doi: 10.1192/bjp.bp.113.141119.
    1. Zwijsen SA, Gerritsen DL, Eefsting JA, Smalbrugge M, Hertogh CM, Pot AM. Coming to grips with challenging behaviour: a cluster randomised controlled trial on the effects of a new care programme for challenging behaviour on burnout, job satisfaction and job demands of care staff on dementia special care units. Int J Nurs Stud. 2015;52(1):68–74. doi: 10.1016/j.ijnurstu.2014.10.003.
    1. Livingston G, Barber J, Marston L, Stringer A, Panca M, Hunter R, et al. Clinical and cost-effectiveness of the managing agitation and raising quality of life (MARQUE) intervention for agitation in people with dementia in care homes: a single-blind, cluster-randomised controlled trial. Lancet Psychiatry. 2019.
    1. Medical Research Council. Developing and evaluating complex interventions - new guidance London. 2016 [Available from: . Accessed 10 Mar 2017.
    1. Hawe P, Shiell A, Riley T. Complex interventions: how "out of control" can a randomised controlled trial be? BMJ. 2004;328(7455):1561–1563. doi: 10.1136/bmj.328.7455.1561.
    1. Surr CA, Gates C, Irving D, Oyebode J, Smith SJ, Parveen S, et al. Effective dementia education and training for the health and social care workforce: a systematic review of the literature. Rev Educ Res. 2017;87(5):966–1002. doi: 10.3102/0034654317723305.
    1. Lichtwarck B, Selbaek G, Kirkevold O, Rokstad AM, Benth JS, Myhre J, et al. TIME - targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms: protocol for an effectiveness-implementation cluster randomized hybrid trial. BMC Psychiatry. 2016;16(233):1–12.
    1. Lichtwarck B, Selbaek G, Kirkevold O, Rokstad AMM, Benth JS, Lindstrom JC, et al. Targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms: a cluster randomized controlled trial. Am J Geriatr Psychiatry. In Press 2017.
    1. Glasgow RE, Lichtenstein E, Marcus AC. Why Don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health. 2003;93(8):1261–1267. doi: 10.2105/AJPH.93.8.1261.
    1. Lichtwarck B, Tverå AM, Røen I. TIME - Targeted Interdiciplinary Model for Evaluation and treatment of neuropscychiatric symptoms - Manual 2nd Edition. Ottestad (Norway): The Research Centre for Age-related Functional Decline and Disease - Innlandet Hospital Trust; 2015. Available from: . Accessed 30 Apr 2017.
    1. Beck JS. Cognitive behavior therapy: basics and beyond. New York: Guilford Press; 2011.
    1. Kitwood T. Dementia reconsidered - the person comes first. Birmingham: Open University Press; 1997.
    1. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in dementia. Biol Psychiatry. 1988;23(3):271–284. doi: 10.1016/0006-3223(88)90038-8.
    1. Barca ML, Engedal K, Selbaek G. A reliability and validity study of the Cornell scale among elderly inpatients, using various clinical criteria. Dement Geriatr Cogn Disord. 2010;29(5):438–447. doi: 10.1159/000313533.
    1. Husebo BS, Ostelo R, Strand LI. The MOBID-2 pain scale: reliability and responsiveness to pain in patients with dementia. Eur J Pain. 2014;18(10):1419–1430. doi: 10.1002/ejp.507.
    1. Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982;140:566–572. doi: 10.1192/bjp.140.6.566.
    1. Folstein MF, Robins LN, Helzer JE. The mini-mental state examination. Arch Gen Psychiatry. 1983;40(7):812. doi: 10.1001/archpsyc.1983.01790060110016.
    1. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–186. doi: 10.1093/geront/9.3_Part_1.179.
    1. David L. Consultation skills for the CBM. In: David L, editor. Using CBT in general practice: the 10 minute consultation. Bloxham: Royal College of general practitioners; 2006. pp. 61–81.
    1. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350:h369. doi: 10.1136/bmj.h369.
    1. Lichtwarck B, Myhre J, Goyal AR, Rokstad AMM, Selbaek G, Kirkevold O, et al. Experiences of nursing home staff using the targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms (TIME) - a qualitative study. Aging Ment Health. 2018:1–10.
    1. Lichtwarck B, Tverå AM, Nystad HL. TID Tverrfaglig Intervensjonsmodell ved utfordrende atferd ved Demens Opplæringsfilm (Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms - an educational film) Mo i Rana: Rana Kommune; 2013 [Available from: . Accessed 30 Apr 2017.
    1. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS-2 tool: designing trials that are fit for purpose. BMJ: British Medical Journal. 2015;350:h2147. doi: 10.1136/bmj.h2147.
    1. Richards DA, Hallberg IR. Complex interventions in health: an overview of research methods. New York: Routledge; 2015.
    1. Holle D, Kruger C, Halek M, Sirsch E, Bartholomeyczik S. Experiences of nursing staff using dementia-specific case conferences in nursing homes. Am J Alzheimers Dis Other Dement. 2015;30(3):228–237. doi: 10.1177/1533317514552320.
    1. Boersma P, van Weert JC, van Meijel B, Droes RM. Implementation of the Veder contact method in daily nursing home care for people with dementia: a process analysis according to the RE-AIM framework. J Clin Nurs. 2017;26(3–4):436–455. doi: 10.1111/jocn.13432.
    1. Chenoweth L, Jeon YH, Stein-Parbury J, Forbes I, Fleming R, Cook J, et al. PerCEN trial participant perspectives on the implementation and outcomes of person-centered dementia care and environments. Int Psychogeriatr. 2015;27(12):2045–2057. doi: 10.1017/S1041610215001350.
    1. Zwijsen SA, Smalbrugge M, Eefsting JA, Gerritsen DL, Hertogh CM, Pot AM. Grip on challenging behavior: process evaluation of the implementation of a care program. Trials. 2014;15:302. doi: 10.1186/1745-6215-15-302.
    1. Spector A, Revolta C, Orrell M. The impact of staff training on staff outcomes in dementia care: a systematic review. Int J Geriatr Psychiatry. 2016;31(11):1172–1187. doi: 10.1002/gps.4488.
    1. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. doi: 10.1136/bmj.h1258.
    1. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions UK Medical Research Council (MRC) guidance: MRC Population Health Science Research Network; 2013 [Available from: . Accessed 12 Dec 2017.
    1. Boersma P, van Weert JC, Lakerveld J, Droes RM. The art of successful implementation of psychosocial interventions in residential dementia care: a systematic review of the literature based on the RE-AIM framework. Int Psychogeriatr. 2015;27(1):19–35. doi: 10.1017/S1041610214001409.
    1. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–1327. doi: 10.2105/AJPH.89.9.1322.
    1. Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013;103(6):e38–e46. doi: 10.2105/AJPH.2013.301299.
    1. Creswell JW, Clark P. Choosing a mixed methods design. In: Creswell JW, Clark P, editors. Designing and conducting mixed methods research. Los Angeles: SAGE Publications,Inc.; 2011. pp. 53–106.
    1. Helse og omsorgsdepartementet (Ministry of Health and Care Services). Forskrift for sykehjem og boform for heldøgns omsorg og pleie (National regulations for nursing homes and residential care) 1998 [updated 21.06.2013. Available from: . Accessed 24 June 2018.
    1. Murad MH, Katabi A, Benkhadra R, Montori VM. External validity, generalisability, applicability and directness: a brief primer. BMJ evidence-based medicine. 2018;23(1):17–19. doi: 10.1136/ebmed-2017-110800.
    1. Lichtwarck B, Selbaek G, Kirkevold Ø, Rokstad AM, Benth JS, Lindstrøm JC, et al. Targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms: a cluster randomized controlled trial. Am J Geriatr Psychiatry. 2018;26(1):25–38. doi: 10.1016/j.jagp.2017.05.015.
    1. Krueger RA, Casey MA. Answering questions about the quality of focus goups research. In: Krueger RA, Casey MA, editors. Focus groups: A practical guide for applied reserach. Los Angeles: Sage publications; 2015. pp. 237–245.
    1. Patton M. Designing qualitative studies. In: Patton M, editor. Qualitative research and evaluation methods. United States of America: Sage Publications, Inc; 2015.
    1. Kada S, Nygaard HA, Mukesh BN, Geitung JT. Staff attitudes towards institutionalised dementia residents. J Clin Nurs. 2009;18(16):2383–2392. doi: 10.1111/j.1365-2702.2009.02791.x.
    1. Dallner M, Elo A-L, Gamberale F. Validation of the general Nordic questionnaire (QPSNordic) for psychological and social factors at work. Copenhagen: Nordic Council of Ministers; 2000.
    1. Lintern T. Quality in dementia care: evaluating staff attitudes and behaviour. Bangor: University of Wales Bangor; 2001.
    1. Wannstrom I, Peterson U, Asberg M, Nygren A, Gustavsson JP. Psychometric properties of scales in the general Nordic questionnaire for psychological and social factors at work (QPS): confirmatory factor analysis and prediction of certified long-term sickness absence. Scand J Psychol. 2009;50(3):231–244. doi: 10.1111/j.1467-9450.2008.00697.x.
    1. Bing-Jonsson PC, Bjork IT, Hofoss D, Kirkevold M, Foss C. Competence in advanced older people nursing: development of 'nursing older people--competence evaluation tool. Int J Older People Nursing. 2015;10(1):59–72. doi: 10.1111/opn.12057.
    1. Krueger RA, Casey MA. Focus groups: a practical guide for applied research. Los Angeles: Sage publications; 2015.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405. doi: 10.1111/nhs.12048.
    1. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280):483–488. doi: 10.1016/S0140-6736(01)05627-6.
    1. Bowen GA. Document analysis as a qualitative research method. Qual Res J. 2009;9(2):27–40. doi: 10.3316/QRJ0902027.
    1. Flick U. Thematic coding and content analysis. In: Flick U, editor. An introduction to qualitative research. London: SAGE Publications Inc.; 2014. pp. 420–438.
    1. Cummings JL. The neuropsychiatric inventory: assessing psychopathology in dementia patients. Neurology. 1997;48(5 Suppl 6):S10–S16. doi: 10.1212/WNL.48.5_Suppl_6.10S.
    1. Rapaport P, Livingston G, Murray J, Mulla A, Cooper C. Systematic review of the effective components of psychosocial interventions delivered by care home staff to people with dementia. BMJ Open. 2017;7(2):e014177. doi: 10.1136/bmjopen-2016-014177.
    1. Nguyen VN, Miller C, Sunderland J, McGuiness W. Understanding the Hawthorne effect in wound research-a scoping review. Int Wound J. 2018;15(6):1010–1024. doi: 10.1111/iwj.12968.
    1. Spector A, Hebditch M, Stoner CR, Gibbor L. A biopsychosocial vignette for case conceptualization in dementia (VIG-Dem): development and pilot study. Int Psychogeriatr. 2016;28(9):1471–1480. doi: 10.1017/S1041610216000338.
    1. Rokstad AM, Vatne S, Engedal K, Selbaek G. The role of leadership in the implementation of person-centred care using dementia care mapping: a study in three nursing homes. J Nurs Manag. 2015;23(1):15–26. doi: 10.1111/jonm.12072.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science: IS. 2009;4:50. doi: 10.1186/1748-5908-4-50.
    1. Scalzi CC, Evans LK, Barstow A, Hostvedt K. Barriers and enablers to changing organizational culture in nursing homes. Nurs Adm Q. 2006;30(4):368–372. doi: 10.1097/00006216-200610000-00009.
    1. Fossey J, Garrod L, Guzman A, Testad I. A qualitative analysis of trainer/coach experiences of changing care home practice in the well-being and health in dementia randomised control trial. Dementia (London, England) 2018:1471301218772178.
    1. Fossey J, Garrod L, Lawrence V, Testad I, Stafford J, Murray J. "we should see her like part of the team": an investigation into care home staff's experiences of being part of an RCT of a complex psychosocial intervention. Aging Ment Health. 2018:1–8.
    1. Beeber AS, Zimmerman S, Fletcher S, Mitchell CM, Gould E. Challenges and strategies for implementing and evaluating dementia care staff training in long-term care settings. Alzheimer’s Care Today. 2010;11(1):17–39.
    1. Roen I, Kirkevold O, Testad I, Selbaek G, Engedal K, Bergh S. Person-centered care in Norwegian nursing homes and its relation to organizational factors and staff characteristics: a cross-sectional survey. Int Psychogeriatr. 2018;30(9):1279–1290. doi: 10.1017/S1041610217002708.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren