The cost-effectiveness of grip on challenging behaviour: an economic evaluation of a care programme for managing challenging behaviour.

OBJECTIVE: The objective of the study was to evaluate the cost-effectiveness of implementing the Grip on Challenging Behaviour care programme (GRIP) on dementia special care units in comparison with usual care. METHODS: A stepped wedge design was used. Challenging behaviour and quality of life were measured using the Cohen Mansfield Agitation Inventory (CMAI) and the QUALIDEM. Quality-adjusted life years (QALYs) were calculated using the EuroQol-5D. Psychoactive medication use (range 0-5 per measurement) and sick leave were registered. Costs included medication, time spent on challenging behaviour and education. Costs and effects were analysed using linear multilevel regression. Incremental cost-effectiveness ratios were calculated. Statistical uncertainty was estimated using bootstrapping. RESULTS: Seventeen dementia special care units participated. GRIP led to improvement on the QUALIDEM subscale social relations (1.6; 95% CI 0.18 to 3.4) and on the use of psychoactive medication (-0.73; 95% CI -1.1 to -0.46) and to a decrease in QALYs (-0.02; 95% CI -0.06 to -0.003). No significant effects on CMAI, sick leave and other QUALIDEM subscales were found. The intervention was not cost-effective in comparison with usual care with regard to CMAI score, QALYs and sick leave. The willingness to pay should be 320€/point improvement on the QUALIDEM subscale social relations and 370€/psychoactive medication less to reach a 0.95 probability of cost-effectiveness. CONCLUSION: It depends on how much society is willing to pay whether GRIP can be considered cost-effective. Because the appropriateness of the current methods for analysing cost-effectiveness in this specific population is uncertain, the positive effects on behaviour, medication and job satisfactions should also be taken in account in the decision making.

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.

BACKGROUND: Caring for people with dementia in dementia special care units is a demanding job. Challenging behaviour is one of the factors influencing the job satisfaction and burnout of care staff. A care programme for the challenging behaviour of nursing home residents with dementia might, next to diminishing the challenging behaviour of residents, improve job satisfaction and reduce the care staff's feelings of burnout. OBJECTIVES: To determine the effects of a care programme for the challenging behaviour of nursing home residents with dementia on the burnout, job satisfaction and job demands of care staff. DESIGN: The care programme was implemented according to a stepped wedge design in which care units were randomly divided over five groups with different time points of starting with implementation. SETTING: 17 Dutch dementia special care units. PARTICIPANTS: Care staff members of the 17 units. INTERVENTION: The care programme consists of an education package and of various structured assessment tools that guide professionals through the multidisciplinary detection, analysis, treatment and evaluation of treatment of challenging behaviour. METHODS: Burnout, job satisfaction and job demands were measured before implementation, halfway through the implementation process and after all the care units had implemented the care programme. Burnout was measured with the Dutch version of the Maslach burnout inventory (UBOS-C, three subscales); job satisfaction and job demands were measured with subscales of the Leiden Quality of Work Questionnaire. Mixed model analyses were used to determine effects. Care staff could not be blinded for the intervention. RESULTS: Of the 1441 questionnaires, 645 were returned (response 45%, 318 control measurements, 327 intervention measurements) by 380 unique care staff members. Significant effects were found on job satisfaction (0.93, 95% CI 0.48-1.38). On the other outcomes, no significant changes in the scores were found. CONCLUSION: Positive effects of using the Grip on Challenging behaviour care programme were found on job satisfaction, without an increase in job demands.

The relationship between small-scale nursing home care for people with dementia and staff's perceived job characteristics.

BACKGROUND: Over the past few decades, new care models that are more resident-oriented and directed toward small-scale and homelike environments have been developed worldwide. The impact of these care models on the quality of life of residents has been studied. However, little research has been conducted to gain insight into how these new care models influence healthcare staff's work environment. This study focuses on the consequences of small-scale care on staff's perceived job characteristics. METHODS: Data were derived from a sample of 136 Dutch living arrangements providing nursing home care for people with dementia (2008/2009), in which 1,327 residents and 1,147 staff participated. The relationship between two indicators of small-scale care (small-scale care characteristics and total number of residents with dementia in facility) and staff's job characteristics (job demands, decision authority, coworker and supervisor support) were studied with multilevel regression analyses. All analyses were adjusted for staff, resident, and living arrangement characteristics when needed. RESULTS: Both indicators of small-scale care were associated with job demands; staff perceived less time and work pressure as more characteristics of small-scale care were integrated and the facility had less residents with dementia in total. Only one indicator was associated with decision authority. As more characteristics of small-scale care were integrated, staff's perceived decision authority was higher. No relationship was found with coworker and supervisor social support. CONCLUSIONS: Knowing that job demands and decision authority are important predictors of job appraisal and well-being, our findings show that small-scale care could have a beneficial impact on healthcare staff's work environment.

Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes.

OBJECTIVES: To optimize care and interventions to improve care, and to reduce staff burden, it is important to have knowledge of the relation between individual neuropsychiatric symptoms and distress of care staff. We therefore explored the relation between frequency and severity of individual neuropsychiatric symptoms and distress of care staff. DESIGN: This is an explorative study with a cross-sectional design. PARTICIPANTS AND SETTING: Care staff was interviewed regarding 432 residents of 17 nursing homes for people with dementia. MEASUREMENTS: Behavioural problems were assessed using the Nursing Home version of the Neuropsychiatric Inventory (NPI-NH) questionnaire. The distress scale of the NPI-NH was used to determine the distress of care staff. RESULTS: Agitation/aggression had the highest mean distress score and was also the most prevalent symptom. Disinhibition and irritability/lability also had high mean distress scores, whereas euphoria/elation, hallucinations and apathy had the lowest mean distress score. The symptom severity of each symptom strongly predicted the distress score, whereas the frequency of the symptoms was a less important factor. CONCLUSIONS: Although some of these findings are in accordance with studies among informal caregivers, there are also notable differences. Apathy caused little distress among care staff. Therefore, care staff might not feel the urgency to explore the causes of this symptom. The findings of this study emphasize the importance of supporting care staff in the management of behavioural problems, especially aggression and apathy.

[Self perceived burden from informal care: construction of the EDIZ-plus]. / Ervaren belasting door mantelzorg; constructie van de EDIZ-plus.

To measure the experienced burden by informal carers (N = 2.444), a 15-item Mokken scale has been developed. This concerns an extended version of the EDIZ ("Ervaren druk door Informele zorg"); several items refer to the pressure of time brought by the combination of labour and care and the consequences for the health of the informal carers are added to the EDIZ. We call this new scale the EDIZ-plus; it concerns a reliable one-dimensional and hierarchical scale which extends from o (no burden) to maximum 15 (severe burden). First, the burden manifests itself in feelings of responsibility of the carer, followed by having difficulty with combining work and family tasks and ultimately exceeding all limits due to too many obligations. In most cases this last group does not only deal with conflicts at home or at work and a decline in their own health, they also experience all other problems in the scale. The presumed limit for overburdening is enclosed by the proposition 'caring put too much pressure on me'. This is a score on the EDIZ-plus of nine or higher. Furthermore, the scale has proved to be usable for several population groups, such as carers of partners and children, parents/parents-in-law and carers of different patient populations (people with dementia, mental disability or a chronic disease). The EDIZ-plus is not only suitable because of its reasonable psychometric qualities, but also because of the usability in different populations.

[Routine outcome monitoring and benchmarking: how can treatment results be compared in a responsible manner?]. / Routine outcome monitoring en benchmarking: hoe kunnen we behandelresultaten op een zorgvuldige manier vergelijken?

BACKGROUND: The structural measurement of the results of treatment under the Dutch mental health services and a comparison of these results between mental health centres help to provide insight into the effectiveness of treatment in general practice. AIM: To provide an overview of the issues that require attention when the results of mental health centres are being compared. METHOD: Documentation, policy information and practical experience with routine outcome monitoring were analysed. RESULTS: We describe the problems that can arise when results obtained by mental health centres are compared and we suggest some solutions for these problems. Important factors that have emerged from our study are as follows: working with routine outcome monitoring is a process of natural growth and involves experiences with several solutions and the making of definitive choices on the basis of experience. CONCLUSION: It is instructive to compare mental health centres with each other and with regards to so-called 'best practices' (benchmarking). However, mental health centres draw on a differing wide mix of patients and use different measurement procedures and instruments. In this article we express the view that in the near future it should be possible to draw meaningful comparisons.

[Trends in the utilization of Dutch mental health services by older adults between 1990-2004]. / Trends in het gebruik van geestelijke gezondheidszorg door ouderen in de periode 1990-2004.

AIM: Because the Dutch population has a growing number of older people, an increasing burden on mental health services is expected. To facilitate policy making for the future, it is important to know what changes there have been in use of mental health services by elderly in the past. This study investigates changes in the use of mental health services by older adults in the period 1990-2004. METHODS: Information about the use of mental health services by older adults was retrieved from the Dutch Psychiatric Case Registers. Population size in these register areas and the unit costs of the different mental health services were taken into account. RESULTS: In total there was an increase in the number of older adults that used mental health services in the period mentioned above. The costs, however, showed a decrease, which was caused by the decrease of expensive inpatient care and the increase of less expensive outpatient care. This was mainly the case until 2002. From this year on the ratio between inpatient and outpatient care stabilized. CONCLUSION: Deinstitutionalization of mental health care for older adults was shown in the period 1990-2002. This means that expensive inpatient care is partly replaced by less expensive outpatient care. As a consequence more older adults can be treated with no rise in costs. Since 2002 deinstitutionalization came to a halt. Because a growing number of older adults will be using mental health services in the future, new forms of outpatient care should be explored.

[Pain and physical (in)activity in relation to cognition and behaviour in dementia]. / Pijn en bewegen in relatie tot cognitie en gedrag bij dementie.

Older persons with dementia may become confronted with a decline in the level of physical activity. Indeed, a positive relationship between physical activity and cognition has been demonstrated. Although the causality of this relationship needs to be confirmed in advanced dementia, particularly animal experimental studies show the possible negative influence of restrained physical activity on behavior of patients with dementia. Patients with dementia, who get immobilized because of agitation and restlessness, may show an increase in these two symptoms. Another cause for reduced physical activity or inactivity may be the experience of pain. Pain experience may even increase in dementia by neuropathological changes in the central nervous system. There is an increasing (inter)national interest for the development of a more reliable assessment and treatment of pain, for the causality of the relationship between pain and physical (in)activity, and for the causality of the relationship between physical (in)activity and cognition in dementia. In the present paper, the various topics will be addressed in this order.

Trends in het gebruik van geestelijke gezondheidszorg door ouderen in de periode 1990-2004.

TRENDS IN THE UTILIZATION OF DUTCH MENTAL HEALTH SERVICES BY OLDER ADULTS BETWEEN 1990-2004: AimBecause the Dutch population has a growing number of older people, an increasing burden on mental health services is expected. To facilitate policy making for the future, it is important to know what changes there have been in use of mental health services by elderly in the past. This study investigates changes in the use of mental health services by older adults in the period 1990-2004. Methods: Information about the use of mental health services by older adults was retrieved from the Dutch Psychiatric Case Registers. Population size in these register areas and the unit costs of the different mental health services were taken into account. Results: In total there was an increase in the number of older adults that used mental health services in the period mentioned above. The costs, however, showed a decrease, which was caused by the decrease of expensive inpatient care and the increase of less expensive outpatient care. This was mainly the case until 2002. From this year on the ratio between inpatient and outpatient care stabilized. Conclusion: Deinstitutionalization of mental health care for older adults was shown in the period 1990-2002. This means that expensive inpatient care is partly replaced by less expensive outpatient care. As a consequence more older adults can be treated with no rise in costs. Since 2002 deinstitutionalization came to a halt. Because a growing number of older adults will be using mental health services in the future, new forms of outpatient care should be explored.

The MDS Challenging Behavior Profile for long-term care.

The objective was to construct a reliable and valid challenging behavior scale with items from the Minimum Data Set (MDS). Exploratory factor analyses of a sample of 656 nursing home residents yielded a 16-item Behavior Profile containing four internally consistent and valid subscales measuring conflict behavior, withdrawn behavior, agitation and attention seeking behavior (alpha range: 0.69-0.80). On a second dataset of 227 nursing home residents, internal consistency, inter-rater reliability and validity against the Behavior Rating Scale for Psychogeriatric Inpatients (GIP) were established. Internal consistency of the subscales ranged between 0.54 and 0.78. The overall inter-rater reliability of the items was 0.53 (kappa); of the scale it was 0.75 (ICC). The MDS Challenging Behavior Profile could potentially be an important contribution to existing clinical MDS-scales but additional studies on reliability, validity and usefulness are needed.

[Small-scale group living for elderly with dementia: a clarification]. / Kleinschalig wonen voor ouderen met dementie: een begripsverheldering.

This article discusses the results of a Concept Mapping, held to clarify the concept of small-scale group living for elderly with dementia. Seventeen experts from different backgrounds formulated 91 statements about small-scale group living. These were subsequently depicted on a concept map with two dimensions: care versus living and individual versus context. The statements were then divided into six clusters by hierarchical cluster analysis. Five of these clusters centred around the arrangements of the individual lives of the residents and the collective lives of residents and staff, while only one held statements about the physical characteristics of small-scale group living. Therefore, it can be concluded from this Concept Map that small-scale group living is not so much determined by the physical characteristics but by the organisational features of the care context.

Construction and validation of a patient- and user-friendly nursing home version of the Geriatric Depression Scale.

OBJECTIVE: To construct a patient- and user-friendly shortened version of the Geriatric Depression Scale (GDS) that is especially suitable for nursing home patients. METHODS: The study was carried out on two different data bases including 23 Dutch nursing homes. Data on the GDS (n = 410), the Mini Mental State Examination (n = 410) and a diagnostic interview (SCAN; n = 333), were collected by trained clinicians. Firstly, the items of the GDS-15 were judged on their clinical applicability by three clinical experts. Subsequently, items that were identified as unsuitable were removed using the data of the Assess project (n = 77), and internal consistency was calculated. Secondly, with respect to criterion validity (sensitivity, specitivity, area under ROC and positive and negative predictive values), the newly constructed shortened GDS was validated in the AGED data set (n = 333), using DSM-IV diagnosis for depression as measured by the SCAN as 'gold standard'. RESULTS: The eight-item GDS that resulted from stage 1 showed good internal consistency in both the Assess data set (alpha = 0.86) and the AGED dataset (alpha = 0.80). In the AGED dataset, high sensitivity rates of 96.3% for major depression and 83.0% for minor depression were found, with a specificity rate of 71.7% at a cut-off point of 2/3. CONCLUSION: The GDS-8 has good psychometric properties. Given that the GDS-8 is less burdening for the patient, more comfortable to use and less time consuming, it may be a more feasible screening test for the frail nursing home population.

Cardiovascular risk factors in cognitively impaired nursing home patients: a relationship with pain?

Cardiovascular risk factors (CRF) such as hypertension and diabetes mellitus favour the development of both vascular dementia (VaD) and Alzheimer's disease (AD). The resulting deafferentation may increase the experience of pain in VaD and in AD. The goal of the present study was to examine the relationship between CRF and pain in a sample of 107 cognitively impaired nursing home patients who had also a chronic pain condition. The prevalence of pain in patients with hypertension or diabetes mellitus was higher (25/41=61% of them had pain) than those without diabetes or hypertension (of whom 24/66=36.4% had pain, p=0.017). In a multivariate logistic regression model (adjusted for gender, age and depression) the presence of diabetes or hypertension was a risk indicator for pain: odds ratio: 3.48, p=0.005, 95% CI: 1.45-8.38. This finding supports the hypothesis that as a result of CRF, disruptions of cortico-cortico and cortico-subcortical pathways occur, and consequently, enhances pain in this group of patients.

[E-mental health interventions for family caregivers of older adults: a review]. / E-mental health interventies voor mantelzorgers van ouderen: een overzicht.

PURPOSE: To present a systematic overview of the different e-mental health interventions for caregivers of older adults. METHODS: Systematic literature research of implemented and evaluated e-mental interventions for caregivers of older adults. RESULTS: Thirteen e-mental health interventions are included: six telephone, one camera and six internet interventions. In general, research on user friendliness and client satisfaction shows positive results. The effectiveness of three e-mental health interventions have been studied. The family-based structural in-home intervention with the computer telephone integrated system shows a decrease in depressive symptoms after six and eighteen month. The telephone linked computer system did not show positive mental health effects for the total group of family caregivers. After online lessons, caregivers were more capable to organize respite care and to manage disruptive and challenging behaviours of the care recipient. Their ability to solve their own problems increased and their subjective burden decreased. A cost analysis of an internet intervention shows a reduction in costs in comparison to regular care. CONCLUSION: E-mental health interventions for caregivers of older adults are encouraging, although research in this field is still in its infancy. Research on the effectiveness and cost-effectiveness of these type of interventions is needed. In addition, the opportunities of internet interventions could be used more extensively.

[The GDS-8; a short, client- and user-friendly shortened version of the Geriatric Depression Scale for nursing homes]. / De GDS-8: een korte, cliënt- en gebruikersvriendelijke versie van de Geriatrische depressie Schaal voor verpleeghuizen.

The objective of this study was to construct a patient- and user-friendly shortened version of the Geriatric Depression Scale (GDS) that is especially suitable for nursing home patients. The study was carried out on two different data bases including 23 Dutch nursing homes. Data on the GDS (n=410), the Mini Mental State Examination (n=410) and a diagnostic interview (SCAN; n=333), were collected by trained clinicians. Firstly, the items of the GDS-15 were judged on their clinical applicability by three clinical experts. Subsequently, seven items that were identified as unsuitable were removed using the GDS-data of the Assess-project (n=77), and internal consistency was calculated. Secondly, with respect to criterion validity (sensitivity, specificity, area under ROC and positive and negative predictive values), the newly constructed 8-item version of the GDS was validated in the AGED data set (n=333), using DSM-IV diagnosis for depression as measured by the SCAN as 'gold standard'. In the AGED dataset, the GDS-8 was internally consistent (alpha=.80) and high sensitivity rates of 96.3% for major depression and 83.0% for minor depression were found, with a specificity rate of 71.7% at a cut-off point of 2/3. The GDS-8 has good psychometric properties. Given that the GDS-8 is less burdening for the patient, more comfortable to use and less time consuming, it may be a more feasible screening test for the frail nursing home population.