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The Effect of a Multicomponent Intervention on Quality of Life in Residents of Nursing Homes: A Randomized Controlled Trial (COSMOS)

Published:January 07, 2019DOI:https://doi.org/10.1016/j.jamda.2018.11.006

      Abstract

      Objectives

      To investigate if the multicomponent intervention of the COSMOS trial, combining communication, systematic pain management, medication review, and activities, improved quality of life (QoL) in nursing home patients with complex needs.

      Design

      Multicenter, cluster-randomized, single-blinded, controlled trial.

      Setting

      Thirty-three nursing homes with 67 units (clusters) from 8 Norwegian municipalities.

      Participants

      Seven hundred twenty-three patients with and without dementia (≥65 years) were cluster randomized to usual care or intervention in which health care staff received standardized education and on-site training for 4 months with follow-up at month 9.

      Measurements

      Primary outcome was change in QoL as measured by QUALIDEM (QoL dementia scale); QUALID (QoL late-stage dementia scale), and EQ-VAS (European QoL–visual analog scale) from baseline to month 4. Secondary outcomes were activities of daily living (ADL), total medication, staff distress, and clinical global impressions of change (CGIC).

      Results

      During the active intervention, all 3 QoL measures worsened, 2 significantly (QUALID P = .04; QUALIDEM P = .002). However, follow-up analysis from month 4 to 9 showed an intervention effect for EQ-VAS (P = .003) and QUALIDEM total score (P = .01; care relationship P = .02; positive affect P = .04, social relations P = .01). The secondary outcomes of ADL function, reduction of medication (including psychotropics) and staff distress, improved significantly from baseline to month 4. Intervention effects were also demonstrated for CGIC at month 4 (P = .023) and 9 (P = .009), mainly because of deterioration in the control group.

      Conclusion and implications

      Temporarily, the QoL decreased in the intervention group, leading to our hypothesis that health care staff may be overwhelmed by the work-intensive COSMOS intervention period. However, the decrease reversed significantly during follow-up, indicating a potential learning effect. Further, the intervention group improved in ADL function and received less medication, and staff reported less distress and judged COSMOS as able to bring about clinically relevant change. This suggests that nonpharmacologic multicomponent interventions require long follow-up to ensure uptake and beneficial effects.

      Keywords

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      References

        • Helvik A.S.
        • Engedal K.
        • Benth J.S.
        • et al.
        Prevalence and severity of dementia in nursing home residents.
        Dement Geriatr Cogn Disord. 2015; 40: 166-177
        • Livingston G.
        • Sommerlad A.
        • Orgeta V.
        • et al.
        Dementia prevention, intervention, and care.
        Lancet. 2017; 390: 2673-2734
        • Tosato M.
        • Lukas A.
        • van der Roest H.G.
        • et al.
        Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: Results from the SHELTER study.
        Pain. 2012; 153: 305-310
        • Husebo B.S.
        • Ballard C.
        • Sandvik R.K.
        • et al.
        Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
        BMJ. 2011; 343: 1-10
        • Husebo B.S.
        • Ballard C.
        • Fritze F.
        • et al.
        Efficacy of pain treatment on mood syndrome in patients with dementia: A randomized clinical trial.
        Int J Geriatr Psychiatry. 2014; 29: 828-836
        • Habiger T.F.
        • Flo E.
        • Achterberg W.P.
        • et al.
        The interactive relationship between pain, psychosis, and agitation in people with dementia: Results from a cluster-randomised clinical trial.
        Behav Neurol. 2016; 2016: 7036415
        • Husebo B.S.
        • Flo E.
        • Aarsland D.
        • et al.
        COSMOS—Improving the quality of life in nursing home patients: Protocol for an effectiveness-implementation cluster randomized clinical hybrid trial.
        Implement Sci. 2015; 10: 131
        • Aasmul I.
        • Husebo B.S.
        • Flo E.
        Description of an advance care planning intervention in nursing homes: Outcomes of the process evaluation.
        BMC Geriatr. 2018; 18: 26
        • Onder G.
        • Liperoti R.
        • Foebel A.
        • et al.
        Polypharmacy and mortality among nursing home residents with advanced cognitive impairment: Results from the SHELTER study.
        J Am Med Dir Assoc. 2013; 14: 450.e7-450.e12
        • Testad I.
        • Corbett A.
        • Aarsland D.
        • et al.
        The value of personalized psychosocial interventions to address behavioral and psychological symptoms in people with dementia living in care home settings: A systematic review.
        Int Psychogeriatr. 2014; 26: 1083-1098
        • Ballard C.
        • Orrell M.
        • Sun Y.
        • et al.
        Impact of antipsychotic review and non-pharmacological intervention on health-related quality of life in people with dementia living in care homes: WHELD—a factorial cluster randomised controlled trial.
        Int J Geriatr Psychiatry. 2017; 32: 1094-1103
        • Flo E.
        • Husebo B.S.
        • Bruusgaard P.
        • et al.
        A review of the implementation and research strategies of advance care planning in nursing homes.
        BMC Geriatr. 2016; 16: 24
        • Corbett A.
        • Husebo B.
        • Malcangio M.
        • et al.
        Assessment and treatment of pain in people with dementia.
        Nat Rev Neurol. 2012; 8: 264-274
        • Husebo B.S.
        • Achterberg W.
        • Flo E.
        Identifying and managing pain in people with Alzheimer's disease and other types of dementia: A systematic review.
        CNS Drugs. 2016; 30: 481-497
        • Ballard C.
        • Howard R.
        Neuroleptic drugs in dementia: Benefits and harm.
        Nat Rev Neurosci. 2006; 7: 492-500
        • Craig P.
        • Dieppe P.
        • Macintyre S.
        • et al.
        Developing and evaluating complex interventions: The new Medical Research Council guidance.
        Int J Nurs Stud. 2013; 50: 587-592
        • Gautun H.
        • Bratt C.
        Bemanning og kompetanse i hjemmesykepleien og sykehjem. Hogskolen i Oslo og Akershus 2014.
        NOVA Rapport, 2014
      1. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons.
        J Am Geriatr Soc. 2009; 57: 1331-1346
        • Gulla C.
        • Selbaek G.
        • Flo E.
        • et al.
        Multi-psychotropic drug prescription and the association to neuropsychiatric symptoms in three Norwegian nursing home cohorts between 2004 and 2011.
        BMC Geriatr. 2016; 16: 115
        • Selbaek G.
        • Engedal K.
        Stability of the factor structure of the Neuropsychiatric Inventory in a 31-month follow-up study of a large sample of nursing-home patients with dementia.
        Int Psychogeriatr. 2012; 24: 62-73
        • Teri L.
        • Logsdon R.G.
        • Peskind E.
        • et al.
        Treatment of agitation in AD—A randomized, placebo-controlled clinical trial.
        Neurology. 2000; 55: 1271-1278
        • Reisberg B.
        Functional assessment staging (FAST).
        Psychopharmacol Bull. 1988; 24: 653-659
        • Ettema T.P.
        • Droes R.M.
        • De Lange J.
        • et al.
        QUALIDEM: Development and evaluation of a Dementia Specific Quality of Life Instrument—Validation.
        Int J Geriatr Psychiatry. 2007; 22: 424-430
        • Weiner M.F.
        • Martin-Cook K.
        • Svetlik D.A.
        • et al.
        The quality of life in late-stage dementia (QUALID) scale.
        J Am Med Dir Assoc. 2000; 1: 114-116
        • Naglie G.
        • Tomlinson G.
        • Tansey C.
        • et al.
        Utility-based quality of life measures in Alzheimer's disease.
        Qual Life Res. 2006; 15: 631-643
        • Schneider L.S.
        • Olin J.T.
        • Doody R.S.
        • et al.
        Validity and reliability of the Alzheimer's disease cooperative study—Clinical global impression of change.
        Alzheimer Dis Assoc Disord. 1997; 11: S22-S32
        • Folstein M.F.
        • Folstein S.E.
        • Mchugh P.R.
        “Mini-Mental State.” A practical method for grading cognitive state of patients for clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Husebo B.S.
        • Ostelo R.
        • Strand L.I.
        The MOBID-2 pain scale: Reliability and responsiveness to pain in patients with dementia.
        Eur J Pain. 2014; 18: 1419-1430
        • Selbaek G.
        • Kirkevold O.
        • Sommer O.H.
        • et al.
        The reliability and validity of the Norwegian version of the Neuropsychiatric Inventory, Nursing Home Version (NPI-NH).
        Int Psychogeriatr. 2007; 20: 1-9
        • Lawton M.P.
        • Brody E.M.
        Assessment of older people—Self-maintaining and instrumental activities of daily living.
        Gerontologist. 1969; 9: 179-186
        • Hawe P.
        • Shiell A.
        • Riley T.
        Complex interventions: How “out of control” can a randomised controlled trial be?.
        BMJ. 2004; 328: 1561-1563
        • Kruger J.
        • Dunning D.
        Unskilled and unaware of it: How difficulties in recognizing one's incompetence lead to inflated self-assessments.
        J Pers Soc Psychol. 1999; 77: 1121-1134
        • Rajkumar A.P.
        • Ballard C.
        • Fossey J.
        • et al.
        Apathy and its response to antipsychotic review and nonpharmacological interventions in people with dementia living in nursing homes: WHELD, a factorial cluster randomized controlled trial.
        J Am Med Dir Assoc. 2016; 17: 741-747
        • Ballard C.
        • Corbett A.
        • Orrell M.
        • et al.
        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.
        PLoS Med. 2018; 15: e1002500
        • Bergh S.
        • Selbaek G.
        • Engedal K.
        Discontinuation of antidepressants in people with dementia and neuropsychiatric symptoms (DESEP study): Double blind, randomised, parallel group, placebo controlled trial.
        BMJ. 2012; 344: e1566
        • Pinnock H.
        • Epiphaniou E.
        • Sheikh A.
        • et al.
        Developing standards for reporting implementation studies of complex interventions (StaRI): A systematic review and e-Delphi.
        Implement Sci. 2015; 10: 42
        • Aasmul I.
        • Husebo B.S.
        • Flo E.
        Staff distress improves by treating pain in nursing home patients with dementia: Results from a cluster-randomized controlled trial.
        J Pain Symptom Manage. 2016; 52: 795-805
        • Aasmul I.
        • Husebo B.S.
        • Sampson E.L.
        • Flo E.
        Advance care planning in nursing homes—Improving the communication between patient, family and staff: Results from a cluster randomized controlled trial.
        Frontiers Psychol. 2018; 9: 2284
        • Gulla C.
        • Flo E.
        • Kjome R.
        • Husebo B.S.
        Optimizing antihypertensive treatment in nursing home patients and its effect on blood pressure.
        J Geriatr Cardiol. 2018; 15: 275-283
        • Banerjee S.
        • Hellier J.
        • Dewey M.
        • et al.
        Sertraline or mirtazapine for depression in dementia (HTA-SADD): A randomised, multicentre, double-blind, placebo-controlled trial.
        Lancet. 2011; 378: 403-411
        • Beerens H.C.
        • Zwakhalen S.M.
        • Verbeek H.
        • et al.
        Factors associated with quality of life of people with dementia in long-term care facilities: A systematic review.
        Int J Nurs Stud. 2013; 50: 1259-1270