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首页> 外文期刊>PLoS Medicine >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
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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

机译：以人为中心的护理培训和以人为中心的活动对住在疗养院中的痴呆症患者的生活质量，躁动和抗精神病药物使用的影响：一项整群随机对照试验

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Background Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost. Methods and findings This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory–Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen’s D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI ?7.39, ?1.15; Cohen’s D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen’s D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group. Conclusions These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting. Trial registration ISRCTN Registry ISRCTN62237498
机译：背景技术躁动是一种常见的，具有挑战性的症状，会影响大量痴呆症患者并影响生活质量（QoL）。迫切需要基于证据的，具有成本效益的社会心理干预措施，以改善这些结果，尤其是在缺乏安全，有效的药物治疗的情况下。这项研究旨在评估以人为中心的护理和社会心理干预的功效，该研究结合了抗精神病药物评论（WHELD）对住在疗养院中的痴呆症患者的生活质量，情绪激动和抗精神病药物的使用，并确定了其成本。方法和研究结果这是一项于2013年1月1日至2015年9月30日进行的随机对照整群试验，该试验比较了WHELD干预与常规治疗（TAU）在英国69个养老院中的痴呆症患者中的使用意向分析。分配给干预措施的所有疗养院均接受了以人员为中心的护理，社交互动和抗精神病药物教育培训（抗精神病复查）的员工培训，然后通过护理人员支持者模型进行持续分娩。主要结局指标是QoL（DEMQOL代理）。次要结果是躁动（Cohen-Mansfield激动量表[CMAI]），神经精神症状（神经精神量表-疗养院版本[NPI-NH]），抗精神病药的使用，整体恶化（临床痴呆评分），情绪（针对痴呆症抑郁的康奈尔量表） ），未满足的需求（坎伯韦尔老年人需求评估），死亡率，互动质量（互动质量量表[QUIS]），疼痛（艾比疼痛量表）和成本。成本是使用成本函数数字与常规成本进行比较得出的。共有847人被随机分为WHELD或TAU，其中553人完成了为期9个月的随机对照试验。干预措施使QoL有了统计学上的显着改善（DEMQOL-Proxy Z得分2.82，p = 0.0042;平均差异2.54，SEM 0.88; 95％CI 0.81，4.28; Cohen D效应大小0.24）。搅动（CMAI Z得分2.68，p = 0.0076;平均差异4.27，SEM 1.59; 95％CI≤7.39，≤1.15; Cohen's D 0.23）和整体神经精神症状（NPI-NH Z得分3.52， p D 0.30）。对中度重度痴呆症患者的益处最大。通过QUIS进行统计，积极护理互动具有统计学上的显着优势（增加19.7％，SEM 8.94; 95％CI 2.12，37.16，p = 0.03; Cohen D 0.55）。在其他结果方面，WHELD和TAU之间没有统计学上的显着差异。使用预先指定的归因模型进行的敏感性分析证实了WHELD干预对DEMQOL-Proxy，CMAI和NPI-NH结果具有统计学上的显着益处。在两个治疗组中，抗精神病药物的使用均处于较低的稳定水平，并且干预措施并未减少药物的使用。与TAU相比，WHELD干预降低了成本，因此，所获得的好处与节省成本有关。主要的局限性在于，抗精神病药物审查是基于护理院内的扩大程序以触发医学审查，而本研究中并未涉及积极的初级护理教育。另一个限制是在该患者组中评估QoL的固有挑战。结论这些发现表明，WHELD干预在QoL，躁动和神经精神症状方面均具有益处，尽管其效果相对较小，而且在可轻松在养老院中实施的模型中节省了成本。未来的工作应考虑在这种情况下如何促进干预措施的可持续性。试用注册ISRCTN注册中心ISRCTN62237498

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