A systematic review of appropriateness and effectiveness of management strategies used for the Behavioural and Psychological Symptoms of Dementia in the residential care setting.

Review question/objective The aim of this review is to identify and synthesise the best available evidence of the appropriateness and effectiveness of different strategies used to manage Behavioural and Psychological Symptoms of Dementia (BPSD) in the residential care setting. What is the appropriateness of different strategies used to manage Behavioural and Psychological Symptoms of Dementia (BPSD) in the residential care setting? What is the effectiveness of different strategies used to manage Behavioural and Psychological Symptoms of Dementia (BPSD) in the residential care setting? This is to be a comprehensive systematic review; as the current research literature available on this topic covers different kinds of evidence. Key Words Residential aged care, Behavioural and psychological symptoms of dementia, Management strategies. Background The phenomenon of interest for this review is dementia and the process of determining how dementia-related behaviours are managed in residential aged care. The impact of people who live in residential aged care who exhibit Behavioural and Psychological Symptoms of Dementia (BPSD) is a significant factor on the management of a facility and the provision of safe care to the person who has the behaviours, and the people who live and work with them 1. The other factor to note is the negative impact that unmanaged dementia related behaviours has on the care staff who look after these people.2 The incidence of dementia is rising throughout the developed world where, on average, currently 7.5% of people over 65 years3 have dementia. In 2009, estimates of the number of Australians with dementia were reported to be 245,000 (over 1.0% of the population). By 2050, the total number is expected to exceed 1,130,000 - in excess of a fourfold increase since 2009.4 In 2005, there were nearly 52,000 Australians newly diagnosed with dementia.5 By 2050, there are projected to be over 385,000 new cases every year, more than the total number of people with dementia in Australia in 2009.6 The people who suffer from dementia often go on to live in residential care, an environment where people of different backgrounds are placed together often with cultural and religious differences, as well as with different physical and cognitive abilities. In this unfamiliar group environment a variety of behaviours manifest and often require management.7 The management of behaviours in Residential Aged Care Facilities (RACFs) is a significant part of the work that is done to create a pleasant living environment for the people who reside there8. In Australia, in 2009 52.6% of people who were residing in a RACF had a diagnosis of dementia and were suffering from some level of BPSD.4 BPSD is the umbrella term that embraces a heterogeneous group of non-cognitive symptoms and behaviours that occur in people with dementia9. These behaviours can manifest as observable symptoms such as aggression (hitting, kicking, and biting) screaming, restlessness, agitation, wandering, culturally-inappropriate behaviour, sexual dis-inhibition, hoarding, cursing and shadowing11. In preparing this systematic review protocol I have read numerous systematic reviews that look at BPSD. Of particular interest to this review is the review done by Blythe et al in 200912. This review looked closely at the non-pharmacological aspects of BPSD management as it relates to agitation. The aim of that review was to develop practice guidelines, which it concluded was not able to be done at that time. This has provided the impetus for this review - the value of guidelines for management based on the best evidence for residential care would be invaluable. As a clinician it is my experience that pharmacological interventions are entered into very early in the management of these symptoms. It is becoming apparent that the practice of the introduction of mood stabilising medication (Sodium Valproate), anti-psychotics and atypical antipsychotics (Olanzapine and Risperidone) and benzodiazepines (Lorazepam) may require a great deal more consideration. As most of the product monographs state, health care professionals should attempt to use non pharmacological therapy first12. This view is supported in the medical care for older persons in residential care facilities produced by the Royal Australian College of General Practitioners which advocates strongly for the use of multiple strategies to deal with BPSD1. It is my experience as a registered nurse that all BPSD management methods are adjunct therapies to each of the other therapies that are used and one therapy cannot be used exclusive of the others. Inclusion criteria Types of participants This review will consider studies that look specifically at people who reside in Residential Aged Care Facilities (RACFs) who exhibit the behavioural and psychological symptoms of dementia in all of their forms. The behaviours only need to require management to be of interest to this study. The participants of interest for this review will be people 65 years and older, regardless of gender, ethnicity, co-morbidities. This will not include acute psycho-geriatric inpatient studies as these studies do not fit with the residential aged care model and are more akin to acute psychiatric care areas. For this systematic review, the following definitions will be used: Residential Aged Care Facilities (RACFs) are defined as a facility which has been subsidised and sanctioned to provide care to older people (over 65 years commonly) who can no longer live independently.1 Behavioural and Psychological Symptoms of Dementia (BPSD) is an umbrella term that embraces a heterogeneous group of non-cognitive symptoms and behaviours that occur in people with dementia.9 Types of intervention/phenomena of interest The focus of interest for this review is dementia and the process of determining how behaviours are managed in residential aged care and if these interventions are appropriate and effective in controlling BPSD. The quantitative component of this review will consider the effectiveness of mainly pharmacological interventions. The interventions are chiefly the use of medication to alter behaviour or clusters of behaviours. The main medication class to be investigated is anti-psychotics as this is the most widely used class of medication. The qualitative component of the review will consider the appropriateness of a broader range of interventions that are employed to manage behaviours of those people who have dementia and the resultant behavioural and psychological symptoms of dementia. The key therapies to be investigated will be: Standard behavioural therapies, e.g., reality orientation, validation therapy, reminiscence therapy; Alternative therapies, e.g., art therapy and music therapy; Complementary therapies, e.g., aromatherapy, bright-light therapy and multi-sensory approaches, Psychotherapies, e.g., cognitive-behavioural therapy and interpersonal therapy. Environmental factors of facility such as design, decoration and lighting. Pharmacological interventions, e.g. antipsychotic medication For this systematic review, the following definitions will be used: Management strategies' will be used to refer to specific interventions designed to limit the impact of an action on the person or on the people whom the person interacts with10. Effective management strategies can be defined as interventions that reduce the manifestation of described symptoms through the explicit use of a single intervention or combination of interventions.14 Appropriateness is the extent to which an intervention or activity fits with or is apt in a situation. Clinical appropriateness is about how an activity or intervention relates to the context in which the care is given.15 Types of outcomes For the quantitative component of the review, the effective management of behaviours will be evidenced through a change in the frequency or severity of the BPSD. The most common and most reliable indicators of effectiveness of outcomes would be in reported incident rates of behaviours manifesting. And these will be the outcomes that will be focused on for the quantitative component of the review. The qualitative component of the review will consider the appropriateness of strategies used to manage BPSD. This section of the review will also look at reported incident rates as it relates to what is appropriate management of behaviours the residents experience and the care givers experiences. Context This review will consider studies that focus on the residential aged care context or studies that could be applied to residential aged care. Types of studies This review will look at both quantitative and qualitative evidence in the form of primary research. The quantitative component will endeavour to look at randomised controlled trials and quasi-experimental trials, however cohort and case control studies will also be considered for inclusion. The qualitative component of the review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. In the absence of research studies, other text such as opinion papers and reports will be considered. Search strategy The search strategy aims to find both published and unpublished studies from the inception of the listed databases to December 2011. A three-step search strategy will be utilised in the search for quantitative evidence and then again in the search for qualitative evidence in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in English will be considered for inclusion in this review. The databases to be searched include: PubMed CINAHL Scopus PsycINFO ProQuest Social Science Journals EMBASE Ageline Mednar Alerts in each database have been set up to inform the researcher of newly published relevant literature. The search also seeks to include unpublished studies where possible using Mednar and ProQuest databases, to eliminate publication bias. The reference lists from identified papers will be searched for additional studies. Initial keywords to be used will be: BPSD or residential or strategies as further detailed and defined in the logic grid below.Table: No Caption available.Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. In the absence of research studies, textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). In the absence of research studies, textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II). The quantitative, qualitative and textual data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. In the absence of research studies, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Conflicts of interest There are no conflicts of interest to declare from either of the reviewers. Acknowledgements As this systematic review will form part submission for the award of Masters in Clinical Science (MScClinSci) for the primary reviewer, a secondary reviewer will only be used for critical appraisal. The authors would like to acknowledge the assistance of Academic Librarian Maureen Bell, Barr Smith Library University of Adelaide

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