Christine R. Kovach

PURPOSE: To extend the original need-driven, dementia-compromised behavior (NDB) model by explaining the consequences of behavioral symptoms for the person with dementia. ORGANIZING CONSTRUCT AND METHODS: Literature is reviewed and the consequences of expressing needs through need-driven, dementia-compromised behaviors are posited. The consequences of need-driven, dementia-compromised behavior (C-NDB) theory is proposed as a framework to improve understanding of the person with dementia and the consequences of behavioral symptoms and unmet needs. FINDINGS: Instead of normative verbal communication, people with significant dementia commonly communicate need via non-normative behaviors, making it difficult for caregivers to know that the person has a need and the extent of such need. Not meeting needs of people with dementia affects the person with dementia, care factors, and contextual factors. Cascading effects occur in which not meeting the original need results in new needs and behavioral symptoms. CONCLUSIONS: This framework indicates the consequences of expressing need behaviorally rather than verbally and shows that caregiver actions might moderate the events that lead to many needs being unresolved. Suggestions are made regarding future research questions deduced from the model.

This study tested the effectiveness of the Serial Trial Intervention (STI), an innovative clinical protocol for assessment and management of unmet needs in people with late-stage dementia. A double-blinded randomized experiment was conducted in 14 nursing homes with 114 subjects. The treatment group had significantly less discomfort than the control group at posttesting and more frequently had behavioral symptoms return to baseline. The group of nurses using the STI also showed more persistence in assessing and intervening than control group nurses did. There was a statistically significant difference between the groups in the use of pharmacological, but not nonpharmacological, comfort treatments. Results suggest that the STI is effective and that effective treatment of discomfort is possible for people with late-stage dementia.

OBJECTIVES: 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. DESIGN: Cluster randomized controlled trial. SETTING: Twenty-one clusters (single independent nursing home units) in 12 nursing homes within the Netherlands. PARTICIPANTS: Residents with advanced dementia (N = 288). INTERVENTION: 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. MEASUREMENTS: 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). CONCLUSION: 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.