Original Study
Coming to Grips With Challenging Behavior: A Cluster Randomized Controlled Trial on the Effects of a Multidisciplinary Care Program for Challenging Behavior in Dementia

https://doi.org/10.1016/j.jamda.2014.04.007Get rights and content

Abstract

Objectives

The Grip on Challenging Behavior care program was developed using the current guidelines and models on managing challenging behavior in dementia in nursing homes. It was hypothesized that the use of the care program would lead to a decrease in challenging behavior and in the prescription of psychoactive drugs without increase in use of restraints.

Design

A randomized controlled trial was undertaken using a stepped-wedge design to implement the care program and to evaluate the effects. An assessment of challenging behavior and psychoactive medication was undertaken every 4 months on all participating units followed by the introduction of the care program in a group of 3 to 4 units. A total of 6 time assessments took place over 20 months.

Setting

Seventeen dementia special care units of different nursing homes.

Participants

A total of 659 residents of dementia special care units. All residents with dementia on the unit were included. Units were assigned by random allocation software to 1 of 5 groups with different starting points for the implementation of the care program.

Intervention

A care program consisting of various assessment procedures and tools, which ensure a multidisciplinary approach and which structure the process of managing challenging behavior in dementia.

Measurements

Challenging behavior was measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory. Research assistants (blinded for intervention status of the unit) interviewed nurses on the units about challenging behavior. Data on psychoactive drugs and restraints were retrieved from resident charts.

Results

A total of 2292 assessments took place involving 659 residents (1126 control measurements, 1166 intervention measurements). The group of residents who remained in the intervention condition compared with the group in the control condition differed significantly in the CMAI change scores between successive assessments [–2.4 CMAI points, 95% confidence interval (CI) –4.3 to –0.6]. No significant effects were found for the control-to-intervention group compared with the group who remained in the control group (0.0 CMAI points, 95% CI –2.3 to 2.4). Significant effects were found on 5 of the 12 Neuropsychiatric Inventory items and on the use of antipsychotics (odds ratio 0.54, 95% CI 0.37– 0.80) and antidepressants (odds ratio 0.65, 95% CI 0.44–0.94). No effect on use of restraints was observed.

Conclusions

The Grip on Challenging behavior program was able to diminish some forms of challenging behavior and the use of psychoactive drugs.

Section snippets

Ethics

The full trial protocol has been published elsewhere.29 The study protocol is in accordance with the declaration of Helsinki and with the Dutch legislation on medical research; it is in agreement with the Conduct Health Research of the Dutch federation of Biomedical Scientific Societies. The study protocol was approved by the Medical Ethics Review Committee of the VU University Medical Centre. The committee stated that, in accordance with Dutch legislation, the study can be performed without a

Results

Of the 22 organizations that originally showed interest in participation, 5 decided not to take part. Four of these organizations declined because of organizational changes in the near future, and 1 organization had planned to introduce their own new approach for the management of behavioral problems. One unit that did participate moved to another location after T3. Only data from T0–T3 were used in this study for this DSCU.

Of the 17 participating organizations, 9 were affiliated with 1 of the

Discussion

The aim of this study was to determine the effect of using the Grip on Challenging Behavior care program on the prevalence of challenging behavior and on the use of psychoactive medication and restraints. The care program was implemented in 17 DSCUs and challenging behavior and the use of psychoactive medication and restraints was measured over a 20-month period. A significant decrease of challenging behavior, measured as differences in total CMAI score between subsequent measurements, was

Conclusions

A small but significant decrease in prevalence of challenging behavior was found after implementation of the Grip on Challenging Behavior program. The program considerably diminished the use of psychoactive drugs, especially antipsychotics and antidepressants, whereas no difference in restraint use was found.

Acknowledgments

The authors would like to thank all involved organizations, their care staff, and their residents for participating.

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    This study was funded by the Netherlands Organization for Health Research and Development (ZonMw). The authors have not entered into an agreement with the funding organization that has limited their ability to complete the research as planned and publish the results. The authors received no further support from any organization for the submitted work; the authors have no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and the authors have no other relationships or activities that could appear to have influenced the submitted work.

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