title: Effects of a Stepwise Multidisciplinary Intervention for Challenging Behavior in Advanced Dementia: A Cluster Randomized Controlled Trial.
abstract: OBJECTIVE
  To assess whether implementation of a stepwise multicomponent intervention (STA OP!) is effective in reducing challenging behavior and depression in nursing home residents with advanced dementia.
  
  
  METHODS
  Cluster randomized controlled trial.
  
  
  METHODS
  Twenty-one clusters (single independent nursing home units) in 12 nursing homes within the Netherlands.
  
  
  METHODS
  Residents with advanced dementia (N = 288).
  
  
  METHODS
  Staff working on intervention units received comprehensive stepwise multidisciplinary training; the control condition received training on general nursing skills, dementia management and pain without the stepwise component.
  
  
  METHODS
  The primary outcome was agitation (Cohen-Mansfield Agitation Inventory (CMAI)). Secondary outcomes included psychotropic medication use, neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and symptoms of depression (Cornell Scale for Depression in Dementia (CSDD), Minimum Dataset Depression Rating Scale (MDS-DRS)). Measurements were made at baseline and 3 and 6 months after the intervention. Multilevel analysis and logistical generalized estimating equations were used to test treatment and time effects. Analysis was on an intention-to-treat basis.
  
  
  RESULTS
  Multilevel modeling revealed an overall effect of the intervention on challenging behavior and depression; CMAI (mean difference -4.07 points, 95% confidence interval = (CI) = -7.90 to -0.24, P = .02), NPI-NH (mean difference -3.57 points, 95% CI = -6.30 to -0.84, P = .005), CSDD (mean difference -1.59 points, 95% CI = -2.49 to -0.69, P < .001), and MDS-DRS (mean difference -0.96 points, 95% CI = -1.40 to -0.52, P < .001) scores were significantly lower in the intervention condition than the control condition. There was a significant reduction of antidepressants (N06A) (OR = 0.32); nonsignificant reductions of antipsychotics (N05A), anxiolytics (N05B), and hypnotic-sedatives (N05C) (odds ratios = 0.69 to 0.90).
  
  
  CONCLUSIONS
  For nursing home residents with advanced dementia and challenging behavior, providing staff with comprehensive training in behavioral management, resulted in improved behavior and less psychotropic medication use.
authors.affiliation: Emgo Institute for Health and Care Research, Amsterdam, The Netherlands.|Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.|Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Marjoleine J C
authors.initials: MJ
authors.lastname: Pieper
authors.affiliation: Emgo Institute for Health and Care Research, Amsterdam, The Netherlands.|Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
authors.forename: Anneke L
authors.initials: AL
authors.lastname: Francke
authors.affiliation: Emgo Institute for Health and Care Research, Amsterdam, The Netherlands.|Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
authors.forename: Jenny T
authors.initials: JT
authors.lastname: van der Steen
authors.affiliation: Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands.
authors.forename: Erik J A
authors.initials: EJ
authors.lastname: Scherder
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center Amsterdam, Amsterdam, the Netherlands.
authors.forename: Jos W R
authors.initials: JW
authors.lastname: Twisk
authors.affiliation: University of Wisconsin-Milwaukee, Milwaukee, Wisconsin.
authors.forename: Christine R
authors.initials: CR
authors.lastname: Kovach
authors.affiliation: Emgo Institute for Health and Care Research, Amsterdam, The Netherlands.|Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Wilco P
authors.initials: WP
authors.lastname: Achterberg
mesh_terms: D000369:Aged, 80 and over; D015897:Comorbidity; D003704:Dementia / Q000150:complications*; D003863:Depression / Q000175:diagnosis / Q000517:prevention & control*; D005260:Female; D006801:Humans; D008297:Male; D020380:Needs Assessment; D009426:Netherlands; D009735:Nursing Homes; D010147:Pain Measurement; D011569:Psychiatric Status Rating Scales; D011595:Psychomotor Agitation / Q000175:diagnosis / Q000517:prevention & control*; D011619:Psychotropic Drugs / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D011619:Psychotropic Drugs
keywords: challenging behavior; dementia; nursing home; psychotropic drug use; stepwise approach