22 May, 13 | by dforbes
I recently participated in a podcast and found this to be an exceptional tool for knowledge exchange. I am pleased to share with you some of the key messages that were highlighted during my interview with Dr. Ann Kolanowski, Director, Hartford Centre of Geriatric Nursing Excellence at the Pennsylvania State University. She had written a commentary on a systematic review of community-based non-pharmacological interventions for managing the behavioral and psychological symptoms of dementia (Brodaty & Arasaratnam, 2012). As an expert in the field, Dr. Kolanowski reflected on the systematic review undertaken, and offered insightful comments and ideas that can be used in practice and policy.
Dr. Kolanowski became interested in non-pharmacological approaches early in her nursing career when physical restraints and chemical interventions were the primary strategies used to manage challenging behaviours in persons with dementia. However, as older adults often have several comorbidities, they were and often continue to be prescribed multiple medications that may result in side effects and reactions especially if more than three drugs are prescribed. Dr. Kolanowski recommended that drugs should only be prescribed as a last resort and when necessary to “start low and go slow”.
Challenges in conducting research that examines the effectiveness of non-pharmacological interventions for managing the behavioral and psychological symptoms of dementia were clearly articulated by Dr. Kolanowski. For example, she claimed that it is difficult to secure funds for non-pharmaceutical studies and to conduct randomized controlled trials because of the difficulty in blinding of the participants and health care providers, and to randomly allocate participants to intervention or control groups. In addition, interventions are typically multi-component and individualized to the participant making it difficult to tease out which component and at what dose makes the difference. Decreasing challenging behaviours may not be the best outcome as these behaviours are often forms of communication. Rather, examining quality of life indicators, which are outcomes of importance to the persons with dementia and their family caregivers, are more appropriate. In spite of all of these challenges, Brodaty and Arasaratnam’s (2012) meta-analysis on the effectiveness of non-pharmacological interventions did reveal an effect size that was equal or better than medications, providing strong evidence for the use of non-pharmacological approaches.
Dr. Kolanowski emphasized that community-based interventions should incorporate activities that the family caregiver can also be engaged in such as going for a walk or playing cards. Family caregivers may need help in recognizing triggers that prompt responsive behaviours and how to avoid these by, for example, identifying pleasant events and keeping to a schedule that the person with dementia prefers. Medications also need to be reviewed with the intent to decrease or eliminate the use of antipsychotic drugs (Campanelli, 2012). Lastly, family caregivers may need help in recognizing their need for respite care.
Future research should determine which components, duration, and dosage of the intervention(s) are most effective in making a difference to outcomes such quality of life and positive affect. Non-pharmacological protocols should be reported in detail in journal articles to capture their complexity, even though this will require increased journal space.
Dr. Kolanowski’s final key messages were: use non-pharmacological approaches first, and adapt a person and family approach to care. The link to the podcast is https://soundcloud.com/bmjgroup/community-based-non.
Brodaty, H. & Arasaratnam, C. (2012). Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry, 169(9), 946-953.
Campanelli, C.M. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(4), 616–631. doi:10.1111/j.1532-5415.2012.03923.x.
Kolanowski, A.M. (2013). Community-based non-pharmacological interventions delivered by family caregivers reduce behavioural and psychological symptoms of dementia. Evidence-based Nursing, 16(2), 67-68. doi:10.1136/eb-2012-101113