Sunday, October 24, 2010

Managing Behavioral Symptoms: Non-pharmacological (OT) interventions help

I recently read the article: Targeting and Managing Behavioral Symptoms in Individuals with Dementia: A randomized trial of a nonpharmacological intervention, and found it interesting for a number of reasons.  I know some of the study info can be kind of dry, but bear with me, because I will explain why it is interesting after I summarize the study.

Here's what they did:

A two-group randomized control trial was done with 272 caregivers and people with dementia, where they were living in the community and had not made plans to find a personal care home.  A nurse met with the caregivers and patients (I don't like the word "patient" but it was used in the study so I will use it here) once to provide education on common medical conditions, and to take blood and urine samples.  The nurse later phoned the caregiver and possibly the doctor with test results.  An OT met with the caregiver and patient up to nine times!  The OT set goals, assessed the situation, helped identify behavioral triggers, and helped create management strategies by: modifying the environments, using assistive devices, simplifying communications and tasks, and engaging the patients in activities.  The OT instructed the caregivers on stress-reduction and self-care techniques.  The OT then followed up with three phone calls.

The results:

The intervention had "immediate and long-term benefits in three areas of clinical significance: symptom reduction (targeted problem behaviors, caregiver upset), life quality (caregiver burden, well-being), and social acceptability (caregiver impressions of study benefits).  These results are, in general, as good as or better than most studies of pharmacological interventions.

Here's why it is really interesting:

I found it validating as an OT, because the study showed that the interventions provided by OTs (together with the nursing) were quite effective.  It seems there is a shortage of good evidence supporting many of our interventions, so it was great to see some evidence that commonly used OT interventions can make a difference.

I found it interesting that it was published in the Journal of the American Geriatric Society, which not a journal commonly associated with rehabilitation articles.  There was very little reference to the fact that the non-pharmacological interventions were actually OT (and nursing) interventions, which was rather disappointing.  However, by being in the JAGS, the information has reached a much broader audience, which means it is not preaching to the converted.  The article was brought to my attention by a psychiatrist.

I found it odd that OT interventions (with a small nursing component) were called "non-pharmacological" interventions, which assumes that the norm is "pharmacological".  Typically, if a caregiver and patient were to enter the doctor's office and complain of some of the problem behaviors described in the article, they would leave with a prescription for a medication such as Haldol, perhaps a prescription for migraine medication and antidepressants for the caregiver, and no further referrals.  Both the caregiver and patient could be taking the medication for years.  However, if you are going to compare the two, I think the OT interventions would be the least expensive approach.  OTs are not really paid all that highly, and we have fewer harmful side-effects.

I was also concerned that the amount of time the OTs in the study were allowed to allocate to the patients compared to what is actually occuring in our healthcare system.  I know when people receive a refferal to see a community OT here, they sure are not receiving 9 sessions with 3 follow-up phone calls.

I guess that I believe that medications prescribed for the purpose of reducing problem behavior should only be used after other options have been explored.  It is chemical restraint, and restraint of any kind should be a last resort.  Many of the medications that alter behavior have harmful side-effects, and as soon as the person stops taking the medications, the behavior returns because new behavior patterns and coping techniques have not been learned.  I have seen too many people suffering from the effects of being over-medicated.                

I want to send a shout-out to the OTs from the study - great job showing that our interventions can be effective.  I hope the healthcare system listens to what the evidence is showing.

Here's the reference:

Gitlin, L.N., Winter, L., Dennis, M.P., Hodgson, N., & Hauck, W.W. (2010).  Targeting and Managing Behavioral Symptoms in Individuals with Dementia: A randomized trial of a nonpharmacological intervention.  Journal of the American Geriatric Society, Vol 58(8), 1465-74.

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