Reducing agitation in care home residents with dementia
Authors: Frances Bunn, Melanie Handley
Journal: The Lancet Psychiatry (2019)

Agitation is common in care home residents with dementia, particularly those with moderate or severe dementia.1Livingston G Barber J Marston L et al.Prevalence of and associations with agitation in residents with dementia living in care homes: MARQUE cross-sectional study.BJPsych Open. 2017; 3: 171-178Crossref PubMed Scopus (62) Google Scholar, 2Selbæk G Engedal K Bergh S The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review.J Am Med Dir Assoc. 2013; 14: 161-169Summary Full Text Full Text PDF PubMed Scopus (146) Google Scholar Agitation can manifest as disruptive vocalisation, restlessness, and repetitive questioning. Such behaviour often indicates an unmet need.3Algase DL Beck C Kolanowski A et al.Need-driven dementia-compromised behavior: an alternative view of disruptive behavior.Am J Alzheimers Dis. 1996; 11: 10-19Crossref Scopus (435) Google Scholar Agitation is associated with lower quality of life for care home residents,4Martyr A Nelis SM Quinn C et al.Living well with dementia: a systematic review and correlational meta-analysis of factors associated with quality of life, well-being and life satisfaction in people with dementia.Psychol Med. 2018; 48: 2130-2139Crossref PubMed Scopus (133) Google Scholar increased costs, and work-related stress in care home staff.5Costello H Walsh S Cooper C et al.A systematic review and meta-analysis of the prevalence and associations of stress and burnout among staff in long-term care facilities for people with dementia.Int Psychogeriatr. 2018; (published online Nov 13.)DOI:10.1017/S1041610218001606Crossref PubMed Scopus (60) Google Scholar Clinical guidance and policy recommends the use of non-pharmacological interventions as first-line treatment for agitation and other challenging behaviours,6NICEDementia assessment, management and support for people living with dementia and their carers.https://www.nice.org.uk/guidance/ng97Date: 2018Date accessed: February 28, 2019Google Scholar but more evidence on the most effective strategies is needed. In The Lancet Psychiatry, Gill Livingston and colleagues report the findings of a cluster-randomised controlled trial7Livingston G Barber J Marston L et al.Clinical and cost-effectiveness of the Managing Agitation and Raising Quality of Like (MARQUE) intervention for agitation in people with dementia in care homes: a single-blind, cluster-randomised controlled trial.Lancet Psychiatry. 2019; (published online March 11.)http://dx.doi.org/10.1016/S2215-0366(19)30045-8Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar of the Managing Agitation and Raising Quality of Life (MARQUE) intervention. A total of ten care homes were randomised to the MARQUE intervention (189 residents) and ten were randomised to treatment as usual (TAU; 215 residents). MARQUE was an evidence-based, manualised training and education intervention aimed at reducing agitation in people with dementia living in care homes. Six interactive sessions were delivered by graduate psychologists to care home staff directly involved in providing care for residents with dementia. Despite consistent delivery and good attendance of care home staff the MARQUE intervention was not effective in reducing agitation. At 8 month follow-up, the adjusted mean difference in Cohen-Mansfield Agitation Inventory score between the two treatment groups was −0·40 (95% CI −3·89 to 3·09; p=0·8226). Furthermore, the prescription of antipsychotics (odds ratio [OR] 0·66; 95% CI 0·26 to 1·69, p=0·3880) and reporting of any abusive behaviours (OR 0·67; 0·43 to 1·05, p=0·0790) were not significantly different between the groups, although both lower in the MARQUE group than the TAU group. The authors conclude that the study does not support the implementation of the MARQUE intervention in care homes. However, the reduction in abusive behaviours and antipsychotic prescribing, although not statistically significant, suggests that the intervention might have had a positive effect on some care home practices. There are several reasons why MARQUE might not have reduced agitation. MARQUE was designed to be scalable and affordable across UK care homes. The intervention involved the provision of six sessions of education and training to care home staff, with sessions aimed at promoting person-centred care, improving communication, and helping staff to understand and respond to distress in people with dementia. In the final session participants were asked to develop action plans specific to their care homes and residents. Although the intervention was carefully developed, it might not have been intensive enough to change the behaviour of staff or care home culture. Education and training alone might be insufficient to embed change and reduce agitation. Although previous trials8Ballard C Corbett A Orrell M et al.Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster-randomised controlled trial.PLoS Med. 2018; 15: e1002500Crossref PubMed Scopus (99) Google Scholar, 9Livingston G Kelly L Lewis-Holmes E et al.A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia.Health Technol Assess. 2014; 18: 1-226Crossref PubMed Scopus (56) Google Scholar have shown positive benefits of staff education this has generally been in the context of intensive multicomponent interventions. Interventions in care homes might not work because researchers give insufficient attention to context and willingness of care homes to engage with innovation.10Goodman C Sharpe R Russell C et al.Care home readiness: a rapid review and consensus workshops on how organisational context affects care home engagement with health care innovation.https://uhra.herts.ac.uk/bitstream/handle/2299/18200/Vanguard_Care_home_readiness_report_FINAL.pdf?sequence=2&isAllowed=yDate accessed: February 28, 2019Google Scholar Reported attendance at the six sessions was satisfactory, however, it is not clear to what extent staff engaged with the process or if learning from the sessions was implemented. For example, although staff were asked to try out strategies between sessions it is unclear whether they did so. Researchers might need to engage in a more systematic approach to context assessment before asking care homes to participate in an intervention.10Goodman C Sharpe R Russell C et al.Care home readiness: a rapid review and consensus workshops on how organisational context affects care home engagement with health care innovation.https://uhra.herts.ac.uk/bitstream/handle/2299/18200/Vanguard_Care_home_readiness_report_FINAL.pdf?sequence=2&isAllowed=yDate accessed: February 28, 2019Google Scholar Additionally, much care home research involves interventions that are delivered by researchers or therapists instead of care home staff.11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar This has implications for translation into real world settings, staff engagement, implementation, and sustainability.12Travers C Brooks D Hines S et al.Effectiveness of meaningful occupation interventions for people living with dementia in residential aged care: a systematic review.JBI Database Syst Rev Implement Rep. 2016; 14: 163-225Crossref PubMed Google Scholar In their conclusions, Livingston and colleagues suggest that future interventions should be multicomponent and include social and activity times for residents with agitation. Evidence11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar, 12Travers C Brooks D Hines S et al.Effectiveness of meaningful occupation interventions for people living with dementia in residential aged care: a systematic review.JBI Database Syst Rev Implement Rep. 2016; 14: 163-225Crossref PubMed Google Scholar suggests that meaningful social activity, particularly when it involves one to one interaction, can reduce agitation in people with dementia. A realist review11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar of multisensory interventions for people with dementia living in care homes sought to identify underlying mechanisms that might make social activity effective for people with advanced dementia living in long-term care. The review suggests that for people with dementia, including those with advanced dementia, access to social and physical stimulation triggers mechanisms such as familiarity, reassurance, recognition, and connection. This in turn leads to a reduction in agitation. However, because the impact on agitation seems to be short-lived,9Livingston G Kelly L Lewis-Holmes E et al.A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia.Health Technol Assess. 2014; 18: 1-226Crossref PubMed Scopus (56) Google Scholar, 11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar regular, sustained interventions are needed.11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar Ensuring social activity is regular and structured might also be effective because it enables care home staff to engage with residents outside of task-based care.11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar In conclusion, the MARQUE study indicates that education and training for care home staff is unlikely to reduce agitation in residents with dementia. Multicomponent interventions that include social and sensory activities might be needed to reduce agitation. Interventions should focus on improving the quality and quantity of interventions between care home staff and people with dementia,8Ballard C Corbett A Orrell M et al.Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster-randomised controlled trial.PLoS Med. 2018; 15: e1002500Crossref PubMed Scopus (99) Google Scholar, 12Travers C Brooks D Hines S et al.Effectiveness of meaningful occupation interventions for people living with dementia in residential aged care: a systematic review.JBI Database Syst Rev Implement Rep. 2016; 14: 163-225Crossref PubMed Google Scholar and providing opportunities for one to one interaction.11Bunn F Lynch J Goodman C et al.Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions.BMC Geriatr. 2018; 18: 303Crossref PubMed Scopus (22) Google Scholar Interventions need to consider contextual factors and align with the priorities and responsibilities of care home staff who care for people with dementia. We declare no competing interests. Clinical and cost-effectiveness of the Managing Agitation and Raising Quality of Life (MARQUE) intervention for agitation in people with dementia in care homes: a single-blind, cluster-randomised controlled trialThe MARQUE intervention was not efficacious for agitation although feasible and cost-effective in terms of quality of life. Addressing agitation in care homes might require resourcing for delivery by professional staff of a more intensive intervention, implementing social and activity times, and a longer time to implement change. Full-Text PDF Open Access