Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial.

BACKGROUND: Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost. METHODS AND FINDINGS: This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group. CONCLUSIONS: These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting. TRIAL REGISTRATION: ISRCTN Registry ISRCTN62237498.

[Nursing workload indices TISS-10, TISS-28, and NEMS : Higher workload with agitation and delirium is not reflected]. / Pflegeaufwandsindizes TISS-10, TISS-28 und NEMS : Erhöhter Arbeitsaufwand bei Agitation und Delir wird nicht erfasst.

BACKGROUND: Financial resources for the treatment of ICU patients requiring high nursing workload are allocated within the German diagnostic-related groups (DRG) system in part through the Therapeutic Intervention Scoring System-10 (TISS-10). TISS-10, however, has never been validated. This study evaluated whether delirium and agitation in ICU were reflected by TISS-10, and also by the established workload indices TISS-28 and Nine Equivalents of Nursing Manpower (NEMS). Secondary aims were if indices correlated, and what effects delirium and agitation had on financial balances. MATERIALS AND METHODS: Analyses were performed retrospectively in 521 datasets from 152 patients. Nursing workload was assessed with TISS-28, TISS-10, and NEMS, delirium with the Confusion Assessment Method for Intensive Care Units (CAM-ICU), and vigilance with the Richmond Agitation-Sedation Scale (RASS). Revenues were retrieved from the institution's patient data management system, and costs calculated with the Budget Calculation Tool 2007 provided by the German Society of Anaesthesiologists. RESULTS: Delirium was found in 36.2 % of patients (n = 55). TISS-28, TISS-10, and NEMS were not higher in patients with delirium, if corrected for mechanical ventilation. TISS-28, TISS-10, and NEMS were significantly higher in deeply sedated and comatose patients (RASS ≤ - 3, p < 0.001), but not in agitated (RASS ≥ 1) and lightly sedated patients (RASS - 1/- 2). TISS-10 and TISS-28 had a linear correlation (r (2) = 0.864). Median financial balances were negative, but much more pronounced in patients with delirium that without (- 3174 € with delirium vs. - 1721 € without delirium, p = 0.0147). CONCLUSION: The standard workload-scores (TISS-10, TISS-28, NEMS) do not reflect higher daily workload associated with patients with delirium and agitation.

Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case.

There is a growing body of evidence on the impact of the environment on health and well-being. This study focuses on the impact of visual artworks on the well-being of psychiatric patients in a multi-purpose lounge of an acute care psychiatric unit. Well-being was measured by the rate of pro re nata (PRN) medication issued by nurses in response to visible signs of patient anxiety and agitation. Nurses were interviewed to get qualitative feedback on the patient response. Findings revealed that the ratio of PRN/patient census was significantly lower on the days when a realistic nature photograph was displayed, compared to the control condition (no art) and abstract art. Nurses reported that some patients displayed agitated behaviour in response to the abstract image. This study makes a case for the impact of visual art on mental well-being. The research findings were also translated into the time and money invested on PRN incidents, and annual cost savings of almost $US30,000 a year was projected. This research makes a case that simple environmental interventions like visual art can save the hospital costs of medication, and staff and pharmacy time, by providing a visual distraction that can alleviate anxiety and agitation in patients.

Experiences of intensive care nurses assessing sedation/agitation in critically ill patients.

BACKGROUND: Patients admitted to the intensive care unit (ICU) will more often than not require sedative and analgesic drugs to enable them to tolerate the invasive procedures and therapies caused as a result of their underlying condition and/or necessary medical interventions. AIM: This article reports a study exploring the perceptions and experiences of intensive care nurses using a sedation/agitation scoring (SAS) tool to assess and manage sedation and agitation amongst critically ill patients. The principle aims and objectives of this study were as follows: to explore nurse's everyday experiences using a sedation scoring tool; to explore and understand nurse's attitudes and beliefs of the various components of assessing and managing sedation among critically ill patients. METHOD: Using a descriptive qualitative approach, semistructured interviews were carried out with a purposive sample of eight ICU nurses within a district general hospital ICU. The interviews focused on nurses own experiences and perceptions of using a sedation scoring tool in clinical practice. Burnards 14-stage thematic content analysis framework was employed to assist in the data analysis process. RESULTS: Three key themes emerged that may have implications not only for clinical practice but for further research into the use of the SAS tool. Benefits to patient care as a direct result of using a sedation scoring tool. The concerns of nursing staff. The implications of using such a tool in clinical practice. CONCLUSION: This paper reinforces the potential benefits to patients as a direct result of implementing the SAS scoring tool and clinical guidelines. Furthermore, it highlights the reluctance of a number of staff to adhere to such guidelines and discusses the concerns regarding less experienced nurses administering sedative agents. Attention was also drawn to the educational requirements of nursing and medical staff when using the SAS scoring tool.

Walking in--initial visualisation and assessment at triage.

This paper reports on one aspect of a larger grounded theory study exploring how nurses undertake the process of initial assessment at triage, specifically the process of 'initial visualisation'. Fourteen A&E nurses from two demographically distinct A&E departments were video-recorded undertaking a total of 38 live triage encounters. The recordings were replayed to the nurses who were asked to say what they were thinking at the time. The nurses' commentaries were recorded, transcribed and analysed using grounded theory methodology. The findings suggested that prior to the initiation of the triage encounter nurses had already assigned a general degree of urgency to the presenting problem. This was based on an immediate intuitive evaluation of 'the look of the patient', which comprised an assessment of 'obvious' physiological signs coupled with an appraisal of the degree of distress expressed. Nurses did this by dimensionalising client attributes and comparing those features considered salient to any given problem against an extensive repertoire of previous cases. The paper concludes by arguing that the process of 'initial visualising' is so central to triage that only research conducted in the actual clinical setting can truly elucidate the process of nurse reasoning.

Assessment and treatment of terminal restlessness in the hospitalized adult patient with cancer.

Terminal restlessness affects a large proportion of patients with cancer at the end of life. It has many different risk factors, presentations, and causes. Management consists of keen assessment, identification and reversal of the causes, and treatment by a combination of pharmacological, environmental, and spiritual interventions.

Terminal restlessness in the nursing facility: assessment, palliation, and symptom management.

Terminal restlessness, sometimes called agitated delirium, is a common occurrence at the end of life. This type of delirium may appear as thrashing or agitation, involuntary muscle twitching or jerks, fidgeting or tossing and turning, yelling, or moaning. Among older adults, especially those in long-term care situations, the delirium may not appear to be very different from previous episodes observed when the resident experienced an infection, exacerbation of a chronic condition, anxiety, pain, or adverse drug reactions. However, delirium at the end of life is usually multifactorial and exacerbated by the progressive shutdown of multiple body systems. Therefore, the effective management of terminal restlessness requires a different approach than the usual care of residents with delirium. For many nurses, this responsibility means adding new clinical knowledge and skills to their practice inventories. This article provides an overview of terminal restlessness, offers assessment guidelines for older adults in long-term care situations who are dying, and describes comfort and symptom management strategies for these individuals.

Assessment of pain and agitation in critically ill infants.

Critically ill infants are subjected to many painful experiences that, if inadequately treated, can have severe physiological and psychological consequences. Optimal management of pain relies on the adequacy of nurses' assessment; this, however, is complicated by another common condition, agitation. A multidimensional assessment is therefore necessary to adequately identify pain and agitation. The aim of this descriptive study was to identify the cues that nurses caring for critically ill infants use to assess pain and agitation. A questionnaire, developed from the literature, was distributed to all registered nurses (85) working in the neonatal and paediatric intensive care units of an Australian teaching hospital. Questionnaires were completed by 41 nurses (a 57 per cent response rate). Results revealed that, except for diagnosis, there were no significant differences between the cues participants used to assess pain and those to assess agitation. Nurses used numerous cues from various sources: most importantly, their own judgement (99 per cent); the parents' judgement (90 per cent); the infant's environment; documentation (78 per cent), and the infant's cues (70 per cent). These findings demonstrate the relevance of the nurse's role in assessment of pain and agitation in critically ill infants. Nurses used cues specific to the critically ill rather than the less sick infant. Results of this study also show the difficulty of differentiating between pain and agitation. Further research on ways of distinguishing between the construct of pain and agitation needs to be undertaken.

Using multi-sensory environments with older people with dementia.

This paper examines the utilization of multi-sensory rooms as an adjunct to the care of older people with dementia. Their evolution into the field of dementia care is explored and analysed. The degree to which the aims of therapy can be realized is addressed in terms of process issues experienced whilst utilizing the therapy in practice. These are initiation of therapy, transfer of patients, selection of patients and resources. On the basis of these findings recommendations are offered, the focus of which is the active promotion of such therapy within the remit of trained nursing staff.

[Isolation rooms in the psychiatric environment]. / Les chambres d'isolement en milieu psychiatrique.

To date, there has been no survey concerning psychiatric isolation rooms in France. We conducted a mail survey in 1993 involving all adult psychiatric care catchment areas covering the French departments. The survey revealed an estimated number of 1560 isolation rooms. Isolation rooms were considered as absolutely necessary in all the departments but also as an unsatisfactory solution by one-third of them. Isolation rooms were usually small and poorly adapted to efficient patient surveillance. Furthermore, equipment was often inadequate, particularly for noise and fire protection. A serious accident (fire, suicide, escape) was reported by large number of departments. The rooms were used for agitated psychotic (84%) and psychopathic (16) people. Although requested by the physician, but also in some cases by the patient, conditions of use and design of isolation rooms may be dangerous both for the patient and the nursing staff. Financial investment devoted to isolation rooms varies greatly and there is no specific control over the number of installation. Construction must comply with precise specifications defined in co-ordination with the experts involved.

Managing costs: the confused, agitated, or suicidal patient.

A program was implemented by clinical nurse specialists to manage the costs of the confused, agitated, or suicidal hospitalized patient. Key strategies used to implement and maintain the program are presented along with clinical and cost outcomes.

A nursing challenge: Assessment and management of agitation in Alzheimer's patients.

1. Agitation in patients with Alzheimer's disease is a pervasive problem. The behaviors associated with agitation may have detrimental effects on the patient, health care providers, and other patients. 2. Management of these behaviors is particularly challenging and, at times, frustrating for nursing personnel. 3. Attempts to identify the causative factors are essential to the development of an individualized plan of care.

Disruptive, institutionalized elderly: a cost-effective intervention.

1. Psychomotor agitation can be decreased without the use of physical or chemical restraints. 2. A structured activity program can be integrated into the treatment plan of disruptive patients. 3. Nurses working in long-term care settings are in positions to be advocates for change.