Nonpharmacological Management of Behavioral Problems in Persons with Dementia: The TREA Model
ABSTRACT : Several subtypes of problem behaviors are related differentially to personal and environmental characteristics. These subtypes are useful in guiding the formulation of an individualized treatment plan. This article presents the TREA-Treatment Routes for Exploring Agitation-approach for individualizing treatment plans for behavioral problems. Such a plan involves several stages: (a) hypothesize which need underlies the agitated behaviors; (b) characterize the way in which the behavior results from the need (eg, Does the behavioral attempt to accommodate the need? Does it express discomfort? Does it attempt to communicate the need?); and (c) provide an intervention that either provides for the unmet need, or, alternatively, when the behavior itself is alleviating the need, provide a method in which the behavior can be accommodated, When an intervention to provide for the unmet need is required, it needs to be matched to the person's sensory, mental, and physical abilities, as well as to the person's habits and preferences. The goal of the plan is to improve the quality of life for the patient, and to reduce the burden on caregivers. Case examples illustrate this approach.
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ABSTRACT: The aim of this study was to investigate the risk factors of institutionalised older people for developing low food intake. Eating difficulties among patients with dementia have been identified in western society and typically progress as dementia advances. Findings from previous studies reflect that low food intake or weight loss might not be a consequence of people with dementia being unable or unwilling to eat independently. The study consisted of observers' training and mealtime observations. Each data collector received two days of didactic and clinical training. Observation was done for two days during lunch and dinner. Four hundred seventy-seven participants were selected from residents with dementia at nine dementia special care units in licensed long-term care facilities in northern and central Taiwan. Data were collected using the Barthel index, Mini-Mental State Examination (MMSE), and the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. The prevalence of low food intake at meals in residents with dementia in LTCF's was 30.7%. Eating difficulty, no feeding assistance, moderate dependence, fewer family visits, being female and older, were six independent factors associated with low food intake after controlling for all other factors. Nursing staff need to assess residents' feeding ability to continue to self-feed. Also, to supervise the feeding of residents with moderate dependency and provide appropriate verbal or physical assistance at meal times is recommended. Constructing strategies to encourage families to visit their older relatives in institutions is recommended.Journal of Clinical Nursing 01/2010; 19(1-2):53-9. · 1.32 Impact Factor
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ABSTRACT: Atypical antipsychotic drugs have been used off label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotics in elderly patients with dementia, the U.S. Food and Drug Administration (FDA) issued black box warnings for several atypical antipsychotics titled "Cerebrovascular Adverse Events, Including Stroke, in Elderly Patients With Dementia." Subsequently, the FDA initiated a metaanalysis of safety data from 17 registration trials across 6 antipsychotic drugs (5 atypical antipsychotics and haloperidol). In 2005, the FDA issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population. Geriatric mental health experts participating in a 2006 consensus conference (Bethesda, Md., June 28-29) reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. EVIDENCE/CONSENSUS PROCESS: The participants concluded that, while problems in clinical trial designs may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient's chart. Drugs should be used only when nonpharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that there is a need for an FDA-approved medication for the treatment of severe, persistent, or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis) that are unresponsive to nonpharmacologic intervention. This article outlines methodological enhancements to better evaluate treatment approaches in future registration trials and provides an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.The Journal of Clinical Psychiatry 06/2008; 69(6):889-98. · 5.81 Impact Factor