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.
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.
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DOI：
10.1371/journal.pmed.1002500
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发表时间：
2018-03
期刊：
影响因子：
15.8
通讯作者：
Fossey J
中科院分区：
文献类型：
--
作者：
Ballard C;Corbett A;Orrell M;Williams G;Moniz-Cook E;Romeo R;Woods B;Garrod L;Testad I;Woodward-Carlton B;Wenborn J;Knapp M;Fossey J
躁动是一种常见的、具有挑战性的症状，影响大量痴呆患者，并影响生活质量（QoL）。迫切需要循证的、具有成本效益的心理社会干预措施来改善这些结果，特别是在缺乏安全、有效的药物治疗的情况下。本研究旨在评估以人为本的护理和心理社会干预的有效性，包括抗精神病药物审查，WHELD，生活在养老院的痴呆症患者的生活质量，激越和抗精神病药物的使用，并确定其成本。这是一项在2013年1月1日至2015年9月30日期间进行的随机对照群集试验，使用意向治疗分析，比较了生活在69家英国养老院的痴呆症患者的WHELD干预与常规治疗（TAU）。所有分配到干预的疗养院都接受了以人为本的护理和社会互动方面的工作人员培训，以及关于抗精神病药物的教育（抗精神病药物审查），然后通过护理人员冠军模式进行持续交付。主要结局指标为生活质量（DEMQOL-Proxy）。次要结局为激越（Cohen-Mansfield激越量表[CMAI]），神经精神症状（神经精神量表-疗养院版[NPI-NH]），抗精神病药使用，整体恶化（临床痴呆评定），情绪（康奈尔痴呆症抑郁量表），未满足的需求（坎伯韦尔老年人需求评估）、死亡率、互动质量（互动质量量表[QUIS]）、疼痛（修道院疼痛量表）和费用。使用成本函数数字与通常成本进行比较来计算成本。总共有847人被随机分配到WHELD或TAU，其中553人完成了为期9个月的随机对照试验。干预使QoL获得统计学显著改善（DEMQOL-Proxy Z评分2.82，p = 0.0042;平均差异2.54，SEM 0.88; 95% CI 0.81，4.28; Cohen D效应量0.24）。在激动方面也有统计学上的显著益处（CMAI Z评分2.68，p = 0.0076;平均差异4.27，SEM 1.59; 95% CI −7.39，−1.15; Cohen's D 0.23）和总体神经精神症状（NPI-NH Z评分3.52，p < 0.001;平均差4.55，SEM 1.28; 95%CI-7.07，-2.02; Cohen's D 0.30）。对中重度痴呆症患者的益处最大。通过QUIS测量，积极的护理互动具有统计学显著性益处（增加19.7%，SEM 8.94; 95% CI 2.12，37.16，p = 0.03; Cohen's D 0.55）。在其他结局方面，WHELD和TAU之间没有统计学显著差异。使用预先指定的插补模型进行的敏感性分析证实了WHELD干预对DEMQOL-Proxy、CMAI和NPI-NH结局的统计学显著性获益。抗精神病药物的使用在两个治疗组都处于较低的稳定水平，干预并没有减少使用。与TAU相比，WHELD干预措施降低了成本，因此所实现的效益与成本节约相关。主要的局限性是，抗精神病药物审查是基于护理之家内的增强过程，以触发医疗审查，并没有在这项研究中涉及积极主动的初级保健教育。另一个局限性是评估该患者组QoL的固有挑战。这些研究结果表明，尽管效应量相对较小，但WHELD干预在生活质量、激越和神经精神症状方面带来了益处，并且在养老院可以轻松实施的模型中节省了成本。今后的工作应考虑如何促进这种情况下干预措施的可持续性。ISRCTN登记ISRCTN 62237498在一项随机分组对照试验中，克莱夫巴拉德和同事测试了一项结合员工培训，社会互动和抗精神病药物使用指导的计划是否改善了生活在英国护理之家的痴呆症患者的生活质量和症状。生活在养老院的痴呆症患者经常会出现躁动和其他难以治疗的症状，并使个人感到痛苦。我们在英国69家护理院进行了为期9个月的临床试验，测试了WHELD计划，该计划结合了员工培训，社会互动和抗精神病药物使用指导。我们发现，接受WHELD计划的护理院在生活质量以及其他重要症状方面有所改善，包括痴呆症患者的焦虑，行为和疼痛。此外，还证明了妇女健康、环境和发展方案的成本效益。研究结果表明，WHELD方法对生活在养老院的痴呆症患者有益。可以以负担得起的方式提供WHELD，以改善这些人的生活，他们往往得不到所需的护理。
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. 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. 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. ISRCTN Registry ISRCTN62237498 In a cluster-randomized controlled trial, Clive Ballard and colleagues test whether a program combining staff training, social interaction, and guidance on use of antipsychotic medications improves quality of life and symptoms among people with dementia living in UK care homes. People with dementia living in care homes often experience agitation and other symptoms that are difficult to treat and distressing for the individual. We tested the WHELD programme, which combined staff training, social interaction, and guidance on use of antipsychotic medications, in 69 UK care homes in a 9-month clinical trial. We showed that care homes receiving the WHELD programme saw improvements in quality of life as well as other important symptoms including agitation, behaviour, and pain in people with dementia. The WHELD programme was also shown to be cost-effective. The findings show that the WHELD approach is beneficial for people with dementia living in care homes. WHELD could be provided in an affordable way to improve the lives of these individuals, who often do not receive the care they need.
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影响因子：
4
作者：
DEAN, R;PROUDFOOT, R;LINDESAY, J
通讯作者：
LINDESAY, J
DOI：
10.1093/gerona/62.8.908
发表时间：
2007-08-01
影响因子：
5.1
作者：
Cohen-Mansfield, Jiska;Libin, Alexander;Marx, Marcia S.
通讯作者：
Marx, Marcia S.
DOI：
10.1093/geronj/44.3.m77
发表时间：
1989-05-01
期刊：
JOURNALS OF GERONTOLOGY
影响因子：
--
作者：
COHENMANSFIELD, J;MARX, MS;ROSENTHAL, AS
通讯作者：
ROSENTHAL, AS
影响因子：
120.7
作者：
Cummings, Jeffrey L.;Lyketsos, Constantine G.;Siffert, Joao
通讯作者：
Siffert, Joao
影响因子：
10.6
作者：
ALEXOPOULOS, GS;ABRAMS, RC;SHAMOIAN, CA
通讯作者：
SHAMOIAN, CA