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Behavior Trial Shows Dementia Benefits
 
 
  from Jules: Will Ry an White be adjusted to support these interventions, these are types of services aging HIV+ patients will need
 
MedPage Today
Published: September 01, 2010
 
Action Points
 
* Explain to interested patients that a randomized trial of occupational therapist/nurse guidance showed improved function at four months for dementia patients cared for at home, and improved well-being and confidence for caregivers.
 
* Note that functional improvement did not differ between intervention and control groups at nine months but that caregivers in the intervention group continued to experience improvement.
 
Patients with dementia had significant short-term improvement in functional and quality-of-life outcomes after four months of home-based behavioral intervention, data from a randomized trial showed.
 
Compared with a control group, patients assigned to the intervention had significantly better scores related to functional dependence and engagement (P=0.03 to P=0.007). Caregivers also had significant improvement in well-being and confidence in performing activities (P=0.002 for both).
 
After four months, significantly more paired patients and caregivers had eliminated at least one caregiver-identified problem (P=0.01).
 
Outcomes at nine months did not differ between the control and intervention groups, although caregivers tended to perceive greater benefits, investigators reported in the Sept. 1 issue of JAMA.
 
"These findings add to an increasing evidentiary base for nonpharmacologic management of patients with dementia," Laura N. Gitlin, PhD, of Thomas Jefferson University in Philadelphia, and coauthors wrote in the commentary that followed their results.
 
"Improvement in patient function, albeit small, compares favorably with pharmacologic trials, yet with no adverse effects or known risks," they added.
 
Few large randomized trials have evaluated treatments for supporting physical function of patients with dementia. Trials of pharmacologic interventions have shown few, if any, benefits related to patient physical function or caregiver burden, the authors wrote in the introduction to their report.
 
Previous studies of nonpharmacologic interventions yielded some promising results, but showed small effect size and focused on outcomes other than functional dependence, they continued.
 
To examine the effects of a biobehavioral intervention on functional outcomes and caregiver stressors, Gitlin and coauthors conducted the Care of Persons with Dementia in their Environments (COPE) trial. The intervention focused on modifiable environmental stressors with a goal of decreasing sensorial, physical, and cognitive demands to bring them more in line with patient capabilities.
 
The intervention included as many as 10 sessions with occupational therapists and two sessions (one by telephone) with an advance practice nurse. The occupational therapists interviewed caregivers to determine patient routines, habits, and interests and caregiver concerns.
 
After reviewing results of cognitive and functional testing, the occupational therapists trained caregivers to modify home environments, activities, and communications to support patient capabilities, to help caregivers identify solutions for concerns, and to reduce stress.
 
The control group for the trial received three 20-minute telephone calls to discuss caregiving challenges -- with trained researchers who were not occupational therapists or nurses -- and educational materials.
 
The primary outcomes for patients were functional dependence, quality of life, frequency of agitated behaviors, and engagement at four months; for caregivers, primary outcomes were well-being, confidence using activities, and perceived benefits at four months.
 
Investigators randomized 237 dyads (patients and their caregivers) to the COPE intervention or a control group. Data collection comprised 209 dyads at four months and 173 at nine months.
 
After four months, investigators assessed the proportion of participants who had improved or worsened and arrived at a net improvement for each of the principal outcomes, all of which favored the intervention group:
 
* Functional dependence: 48.5% for the intervention group versus 29.3% for the control group, P=0.02
* Daily activities dependence: 61.6% versus 43.7%, P=0.03
* Activity engagement: 12.7% versus -1.9%, NS
* Perceived change in well-being: 46.1% versus 19.6%, P=0.007
* Confidence using activities: 31% versus 4.7%, P=0.005
 
At nine months, the two groups did not differ significantly with respect to the primary outcomes. Significantly, however, caregivers in the intervention group reported a "great deal" of improvement in their lives (P<0.001), in their disease understanding (P=0.001), in their confidence managing behaviors (P<0.001), in making their life easier (P<0.001), in their ability to care for patients (P<0.001), in patients' quality of life (P<0.001), and in their ability to keep patients home (P=0.02).
 
The authors noted several limitations of the study: inability to determine the active component of the intervention, generalizability of the results, and a disparity in staff time to provide and explain information to the two groups.
 
"Because most patients live at home with functional decline, a nonpharmacologic, biopsychosocial-environmental intervention may positively contribute to disease management," the authors wrote in conclusion.
 
The authors reported that they had no relevant disclosures.
 
Primary source: Journal of the American Medical Association
Source reference:
Gitlin LN et al. "A biobehavioral home-based intervention and the welo-being of patients with dementia and their caregivers" JAMA 2010; 304: 983-991.
 
 
 
 
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