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Nonpharmacologic Interventions for Agitation and Aggression in Dementia
Comparative Effectiveness Reviews, No. 177
Investigators: Michelle Brasure, PhD, MSPH, MLIS, Eric Jutkowitz, BA, Erika Fuchs, MPH, PhD, Victoria A Nelson, MSc, Rosalie A Kane, PhD, Tetyana Shippee, PhD, Howard A Fink, MD, MPH, Tonye Sylvanus, MD, MPH, Jeannine Ouellette, Mary Butler, PhD, and Robert L Kane, MD.
Author Information and AffiliationsStructured Abstract
Objective:
To assess the efficacy, comparative effectiveness, and adverse effects of nonpharmacologic interventions for agitation and aggression in individuals with dementia.
Data sources:
Ovid MEDLINE®, Ovid Embase®, and the Cochrane Central Register of Controlled Trials bibliographic databases; hand searches of references of relevant studies.
Review methods:
Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials evaluating nonpharmacologic interventions to manage agitation/aggression in individuals with dementia in nursing home, assisted living, or community settings. We analyzed outcomes of agitation/aggression, general behavior, patient quality of life, admission to long-term care, and staff and caregiver outcomes related to patient behavior and care burden. We assessed risk of bias, extracted data, and evaluated strength of evidence for each comparison and outcome. We analyzed pooled estimates to assess efficacy and comparative effectiveness. We conducted a qualitative analysis when data could not be pooled.
Results:
We identified 126 unique randomized controlled trials as of July 2015. Patient-level interventions involving music, aromatherapy with lavender, and bright light were similar to usual treatment or attention control at managing agitation/aggression in people with dementia (low-strength evidence); interventions tailored to recipients' skills, interests, or both were similar to usual care in managing agitation/aggression in people with dementia (low-strength evidence). Care delivery–level interventions (dementia care mapping and person-centered care) were similar to usual care in managing agitation/aggression in people with dementia (low-strength evidence). Evidence was insufficient to draw conclusions on the effectiveness of most caregiver-level interventions in managing agitation/aggression in people with dementia; caregiver interventions targeting caregiver skills and behavior were similar to attention control in managing agitation/aggression (low-strength evidence). However, these interventions show benefits in caregiver confidence in caregiving and caregiver distress. Adverse effects were rarely reported.
Conclusions:
Although many trials have been conducted to determine effective nonpharmacologic interventions for agitation/aggression in dementia, which is a critical topic, the evidence base is weak because of the variety of comparisons, measurement issues, and other methodological limitations. When evidence was sufficient to draw conclusions about effectiveness for a group of interventions, agitation/aggression outcomes were typically similar to those of control groups. Future research is needed to guide providers and informal caregivers toward effective interventions for agitation/aggression in dementia.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Criteria for Inclusion/Exclusion of Studies in the Review
- Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies To Answer the Key Questions
- Data Abstraction and Data Management
- Assessment of Methodological Risk of Bias of Individual Studies
- Data Synthesis
- Grading the Strength of Evidence for Major Comparisons and Outcomes
- Assessing Applicability
- Results
- Literature Search and Screening
- Patient-Level Nonpharmacologic Interventions for Agitation/Aggression in Individuals With Dementia in Nursing Homes and Assisted Living Facilities
- Care Delivery-Level Nonpharmacologic Interventions for Agitation/Aggression in Individuals With Dementia in Long-Term Care Settings
- Patient-Level Interventions for Community-Dwelling Individuals With Dementia
- Caregiver-Level Interventions for Community-Dwelling Individuals With Dementia
- Discussion
- References
- Abbreviations
- Appendix A Search Strategy
- Appendix B Excluded Studies
- Appendix C Patient-Level Interventions for Agitation/Aggression in Nursing Home and Assisted Living Facilities
- Appendix D Care Delivery–Level Interventions for Agitation/Aggression in Nursing Home and Assisted Living Facilities
- Appendix E Patient-Level Interventions for Agitation/Aggression in Community-Dwelling Individuals With Dementia
- Appendix F Caregiver-Level Interventions for Agitation/Aggression in Community-Dwelling Individuals With Dementia
- Appendix G References for Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-00016-I. Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, MN
Suggested citation:
Brasure M, Jutkowitz E, Fuchs E, Nelson VA, Kane RA, Shippee T, Fink HA, Sylvanus T, Ouellette J, Butler M, Kane RL. Nonpharmacologic Interventions for Agitation and Aggression in Dementia. Comparative Effectiveness Review No. 177. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2012-00016-I.) AHRQ Publication No.16-EHC019-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00016-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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