This weeks’ blog is by Ewan James, Assistant Psychologist at Hertfordshire University NHS Trust (e.james27@nhs.net)

Behavioural and emotional changes are common in those living with dementia. Such phenomena are referred to as ‘Behaviours that Challenge’ (BtC), and include aggression, self-harm, avoidance, depression, shouting, and a lack of self-care amongst other things. While the behaviours often ‘challenge’ the environments in which they are enacted, they typically reflect the person’s misinterpretation of events and/or their attempts to meet their own basic needs: to feel safe and respected, to gain a sense of control and/or feeling of belonging, etc. As such, devising approaches to meet people’s needs, without them feeling overcontrolled, is a management strategy used for BtC.CAIT is an evidence-based training package for caregivers of people living with dementia . It recognises the skills of carers. In its ‘magpie approach’ to training it borrows from the retail sector, police and armed forces. While the behaviours often ‘challenge’ the environments in which they are enacted, they typically reflect the person’s misinterpretation of events and/or their attempts to meet their own basic needs: to feel safe and respected, to gain a sense of control and/or feeling of belonging, etc. As such, devising approaches to meet people’s needs, without them feeling overcontrolled, is a management strategy used for BtC.

BtC can be very distressing for those living with dementia, and for those around them (i.e. carers, family members). NICE guidelines advocate that non-pharmaceutical and person-centred approaches should be used in the first instance to manage these behaviours. This is because some of the medications have major side-effects, including worsening the dementia and causing physical harm. Despite NICE’s recommendations, there are relatively few evidence-based training programmes focusing on non-drug interventions. Communication and Interaction Training (CAIT) was developed to fill this space with a strong focus on the evidence base.CAIT was developed as face-to-face training in 2015. An online version was created during the COVID-19 pandemic. It has now been rolled out across the UK, including to over 20 NHS trusts. CAIT builds on existing frameworks to provide skills to caregivers that can be used across all settings (e.g. institutional settings, family settings etc.). Its content reflects the new national guidance from the British Psychological Society on ‘Psychological alternatives to medication’. The developers of CAIT were some of the main authors of the BPS’s guidelines .

The CAIT programme is designed to improve the ‘dementia care literacy’ of clinical staff and family members. In doing so, it aims to provide a common language around dementia care which will ultimately improve the consistency of care for those living with dementia. A key premise of CAIT is that it recognises the existing skills of carers and aims to build on these: carers are seen as ‘experts by experience’ in managing BtC, and the CAIT programme helps to bring carers’ existing skills into conscious awareness.
CAIT has borrowed from evidence-based practices in de-escalation training from the clinical and retail sectors and from the police and armed forces. The programme is partly information based and partly skills based. It has key psychoeducational elements, looking in-depth at presentations of BtC, as well as providing information on dementia more generally. It includes four skill-based modules, which are: 1) Core communication skills; 2) Adaptations for communicating with people living with dementia; 3) Communicating around intimate care tasks; 4) Use of care plans and delivery of complex care. To explore and highlight these skills, each module uses videos and animations. The concepts are brought to life with a case study of a man living with dementia named Karim which is referenced throughout.

As CAIT is now being used in numerous NHS organisations across the UK, several studies have been conducted. CAIT is regarded as a compendium of good practice and contains material from many national and international experts (Tom Kitwood, Teepa Snow, Alzheimer’s Society, etc.). Individual sections of the programme are supported with empirical studies, some conducted as part of the BPS’s guidelines. Further, in 2022 a pre-post study by Ian James and colleagues examined the impact of CAIT with 21 members of clinical staff in an NHS Trust .. This study investigated changes in staff’s ‘confidence in dementia care’ after completing the programme. During this pilot study, participants showed greater awareness of more specific and technical strategies post-training. A recent study by Sophie Trees .aimed to assess whether clinical staff’s self-perceived dementia care abilities improved after completing the CAIT programme. Participants reported that their confidence, their ability to communicate and their ability to meet patients’ health care needs all improved after completing the programme. Training did not improve knowledge scores; however, this is likely to be because staff already had expert knowledge of dementia. Such studies show that the CAIT programme is effective in building on carers’ existing skills and imp roving their confidence to provide effective care to those living with dementia. As more care staff complete the CAIT programme in organisations and NHS Trusts across the UK, studies with larger samples of carers can be completed.CAIT is supported by a book 5 ,worksheets, and a series of freely available animations which can be accessed via youtube (@Ian James Dementia).

References
1. James, E., & Stapleton, S. (2023). Development of communication and interaction training (CAIT): A compendium of evidence-based tools for supporting people living with dementia who communicate signs of unmet needs. Journal of Dementia Care, 31(2), 27–32.
2. James, I. A., et al. (2024). First line psychosocial alternatives to psychotropic medication for Behaviours that challenge in dementia care: A toolkit for health and social care practitioners. The British Psychological Society.
3. James, I. A., Safrova, M., & Kamal, O. (2022). Use of CAIT in acute hospitals and physical health settings: The Solihull teaching (p. 158). FPOP Bulletin, British Psychological Society.
4. Trees, S., James, I., Stapleton, S. Rippon, D. (2024). A pre and post evaluation of the communication and interaction training programme for professionals in dementia care. Psychology and Psychotherapy. (https://doi.org/10.1111/papt.12568)
5. James, I. A., & Gibbons, L. (2019). Communication skills for effective dementia care. Jessica Kingsley: London.