Preventing Aggression in Veterans with Dementia

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6. PROJECT SUMMARY/ABSTRACT Project Background/Rationale Dementia is one of the most costly chronic conditions in the VA.1 In 2008, 175,621 VA patients had a dementia diagnosis; and the prevalence will increase to 218,017 in 2017.1 Although dementia is primarily defined by memory disturbances, many financial and psychosocial costs are associated with its frequent concurrent medical disorders and psychological/behavioral disturbances. The 2008 Dementia Steering Committee recommended that the VHA fund more research on nonpharmacologic interventions to address behavioral disturbances that occur in 80% of persons with dementia. The investigators of this study have a sustained record of scientific findings that point to the urgent need for new approaches to address aggression, which occurs in 40% of Veterans with dementia and often is not addressed,2 leading to increased institutionalization, injuries, and use of antipsychotic medications.3 A recently completed HSR&D IIR grant4 (IIR 01-159-2), "Causes and Consequences of Aggression in Persons with Dementia," found that pain was among the strongest predictors of aggression.5 The prevalence of pain in persons with dementia is known to be about 50%.6 Project Objectives/Aims Innovative approaches are urgently needed to replace the model of treating aggression with tranquilizing medications. No medications are more than modestly efficacious for treating aggression in persons with dementia. However, antipsychotic medications are commonly prescribed, despite limited efficacy and "black- box" warnings of the increased mortality and morbidity associated with these medications in persons with dementia. We have developed an innovative, psychoeducational intervention that aims to prevent the development of aggression in dementia patients with pain and is guided by empirical evidence regarding mutable risk factors for aggression. As such, the objectives of this proposal are to assess whether this intervention, Preventing Aggression in Veterans with Dementia (PAVeD), 1) decreases incidence of aggression; 2) decreases pain and depression; 3) decreases caregiver burden and improves the caregiver- patient relationship; 4) increases pleasant events; and 5) decreases injuries, use of antipsychotic medication, and nursing-home use. Project Methods The proposed project is a randomized, controlled trial of PAVeD, a 6-8 session, home-based psychoeducational, caregiver/patient intervention. We will recruit 220 dyads (patients with mild-to-moderate dementia and pain who receive care in primary care clinics, and a primary caregiver). Dyads will be randomized to the PAVeD intervention or to an enhanced usual primary care condition (EU-PC). PAVeD uses didactics, role-playing, and multimedia (e.g., books and DVDs). The 6-8 modules will include 4 core modules that address recognizing and treating pain, increasing pleasant activities, and improving patient-caregiver communication. Two to 4 additional elective sessions, selected according to the needs of the dyad, further enhance skills related to these core topics. The EU-PC will include providing the patient and caregiver educational materials on dementia and pain, notifying the primary care provider of the patient's level of pain, and 8 weekly supportive telephone calls to caregivers. The PAVeD group will also receive all EU-PC components.