Management of Dementia, Article Critique Example

Citation

Authors: Laura N. Gitlin, Laraine Winter, Marie P. Dennis, Nancy Hodgson, and Walter W. Hauck

Date: August 2010

Title of Article: Targeting and Managing Behavioral Symptoms in Individuals with Dementia: A Randomized Trial of a Nonpharmacological Intervention

Name of Journal: Journal of the American Geriatrics Society

Volume and Pages: Volume: 58, Issue: 8, Pages: 1465-1474

Topic description

The title is about managing behavioral symptoms common in individuals suffering from dementia. Dementia is a medical condition characterized by the loss of function of the brain. Dementia affects language, memory, judgment, thinking, and behavior. The management of neuropsychiatric behaviors has challenged researchers and caregivers in providing care to individuals suffering from dementia. The symptoms of behavior occur throughout the course of the disease, are common, consume a lot of time in care giving and have a profound effect on families. Great risk for nursing home experience, high care costs, and high rate of mortality are other matters pertinent to dementia problems.

This article used the Advancing Caregiver Training (ACT) approach in which the researcher used randomization. The participating caregivers were in two broad groups. One group received intervention and the other did not. The ACT approach included sixteen weeks with two nursing sessions and up to nine occupational therapy (OT) sessions. There was also a 16-24 week period; maintenance phase, carrying telephone occupational therapy contacts aimed at strengthening the strategy. According to the intervention and results, the caregivers who used the strategy were able to report an improvement on continuously using the ACT approach. This supports recent suggestions by researchers that Non-pharmacological interventions are necessary to address the problem behaviors in individuals with dementia.

Major and minor objectives

The main objective of the journal was to examine various effects of some of the interventions used, by families, to contain upsetting behaviors depicted by members suffering from dementia. A minor objective in the journal included the establishment of management strategies, acceptable to address the behavior problems common in persons suffering from dementia. Another minor objective was to discover other illnesses in the victims of dementia since some of them could not tell what they felt. Yet another minor objective was to avail information to the caregivers on some medical conditions, which worsen problem behaviors. These conditions included constipation, pain, and dehydration.

Concepts by the authors

One crucial concept in the article is that problem behaviors are a result of factors, which reflect the domains. The domains focused on caregiver, patient, or environment. Based on the patient, they included discomfort or pain, unmet needs and incipient medical condition amongst others. Based on caregiver, they included communication style and stress. In terms of the environment, they included clutter and hazards amongst others. Another concept involved the stress health model. This is a model suggesting that stress is a condition affecting the thinking patterns of individuals and that it contributes to the overall state of well being in a person. In the study, the article uses this model to relate the caregiver distress and the problem behaviors common in individuals with dementia. Problem behavior is another concept in the article, although not well defined by the author. Problem behavior refers to the behavior by an individual suffering form dementia. These problem behaviors include refusing care by dementia victims and wandering from home amongst others.

Theory and research methods

The author uses the Advancing Caregiver Training (ACT) methodology in the article. ACT is a method with a design that focuses on problem behaviors that are most troublesome according to caregivers. This method also gives ways of effective management of the problems. The hypothesis in this case was that the patient-caregiver dyads would face the problem behavior and the caregiver receives reduced upsets than one in the group with no-treatment control.

The author uses ACT in intervention. Here, the concept of ACT is that problem behaviors come because of related factors, which reflect three sectors: caregiver based, patient based, and environment based. The author uses the model in the identification and modifications of possible triggers, in the above domains, to enable caregivers reduce, eliminate, or prevent problem behaviors. The ACT provided effective management skills for problem behaviors to help reduce caregiver upset. The ACT involved two phases; sixteen weeks with 2 nursing sessions and up to 9 occupational therapy sessions and 16-24 week period carrying three brief telephone contacts on occupational therapy to strengthen the strategy. The caregivers and occupational therapists held a meeting to review targeted problem behaviors and introduce intervention goals. The meeting also deliberated on the home environment concerning potential hazards and patient way finding and interactions between caregivers and the patients. The caregivers met with an advanced nurse who provided education concerning medical situations that worsen problem behaviors. In the process, there was the diagnosis of patients to determine other diseases that were affecting them.

Sampling criteria and characteristics

The author used participants from mailings and media announcements by social agencies and recruited between 2003, December and 2007 March. The interested caregivers received an explanation of the study procedures. The caregivers used return post cards or telephones to contact the research team. The eligible caregivers lived with persons with Mini-Mental State Examination (MMSE) or dementia. The MMSE was less than 24 and the individual aged 21 and above. The caregivers were English speaking, not actively seeking nursing placement, planning to live in the area for 6 months, reporting upset and managing problem behaviors. The criteria excluded those suffering from terminal illnesses and with less than six months of life expectancy, receiving cancer treatment, and those who had underwent three and above hospitalizations three years before the study. The sample size was two hundred and seventy two caregivers.

Main ideas and findings

After sixteen weeks of the study, the caregivers receiving intervention reported an improvement of 67.5%. From the caregivers in the no-treatment control, 45.8% reported improvement. The study also proved that an approach identifying and modifying three possible problem behavior triggers has positive effects, which are immediate. The approach has effect on the caregiver upsets and the leading problematic behavior according to the caregivers. The study also discovered caregiver benefits including fewer burdens, less depressive symptomatology, better well being, less upset with problem behaviors and enhanced skills. The ACT model showed benefits to be immediate and long-term in three clinical areas. The areas include symptom reduction, life quality, and social acceptability. According to the findings, there is no universal way of operationalizing behaviors related to dementia.

The results are valid. However, it is worth to note that, they do not give a conclusive answer on a working method to address problems related to dementia. According to the Act model, there are shortcomings associated with it. The model simply did not include some notable individuals in the study. This is because the criteria for sampling involved exclusion. The researchers worked as a team and thus the article is a peer review, which gives it authority in the field. It also involved the caregivers themselves, people who are in real contact with the patients at homes. There are findings, which have come unexpected in the study. Some improvements in the group received no intervention.

Conclusions

The authors cite a limitation in the approach used. They assert that the problems according to the caregivers may not be necessarily comparable in terms of the safety concerns they pose and their frequency of occurrence. Problems noted as most distressing might stop distressing some time in the future and thus this is another weakness of the ACT approach. From this research, the group with no treatment showed some positive report and thus we can question the results from the caregivers receiving intervention. It is possible for caregivers for caregivers to benefit by discussing their feelings and experiences. However, the study is evidence, which supports the importance of Non-pharmacological interventions in dealing with problems of dementia and related illnesses.

The data support the conclusions by the author. For example, a higher percentage from caregivers with interventions report improvement as compared to the control group. However, the author makes clear that some other factors could be responsible for improvement in the control group. Therefore, there is no any single approach, which can solve the behavior problems of dementia.

Reflection

The author has failed to give clear definitions of the key concepts and thus we cannot understand some terms such as stress health model amongst others. The authors have not given a clear explanation of the figures in the tables presented. The research only focuses on patients in the home setting alone yet much the authors could have considered those admitted in the hospitals.

Because of the stratification and exclusion criteria, this study might introduce a bias.

The study description is clear, and this can allow replication. The authors suggest further studies to help unravel solutions for behavior problems in the field.

The research will help the nursing practice a lot considering that medications for dementia and related conditions are not helping victims. This is one of the ways in which we can involve Non-pharmacological alternatives to treat dementia. Therefore, further research is necessary. This will need to be comprehensively involving all the caregivers attending to all types of dementia victims.

The crucial thing learned in the article is the ACT approach, and its contribution in the treatment of dementia. This is a milestone to solving the problem behaviors common in dementia victims. Researchers will continue to unravel many other approaches that are applicable in this situation.