The report is a product of the VA/HSR Evidence Synthesis Program.

Healthcare Team Interventions for Older Adults with Distress Behaviors

Takeaway: Novel interventions to reduce distress behaviors among older adults that feature both healthcare worker (HCW) education and skills training along with patient management intervention activities have beneficial impacts on patient quality of life, reduction in antipsychotic use, and possibly distress behaviors. Less complex interventions, for example those focusing on HCW education only, appear less likely to lead to long-term desired effects. It is unknown how these interventions impact staff outcomes such as burnout.

Older adults with complex medical disorders (e.g., dementia, serious mental illness, multiple chronic medical conditions) have a high prevalence of distress behaviors, such as physical or verbal aggression, repeated vocalizations, and/or disengagement. Exacerbation of these symptoms is likely due to vulnerability to environmental factors such as under- or over-stimulation, or unmet medical, physical, emotional, and social needs. Distress behaviors can also cause significant challenges to the ability of healthcare systems generally, and for clinical providers, in particular, to deliver needed care. These challenges can cause distress for healthcare workers and overwhelm limited resources in long-term care settings, restricting the ability to identify appropriate safe care settings for older patients and placing tremendous pressure on family members.

To better address underlying and unmet patient needs – and to reduce distress behaviors in a productive and safe work environment, it is imperative that health systems develop evidence-based, effective approaches to support and prepare healthcare teams around this aspect of patient care. Thus, VA’s Evidence Synthesis Program (ESP) Center located at the Durham VA Medical Center recently conducted a systematic review to evaluate the effect of healthcare team-focused interventions intended to reduce patient distress behaviors across residential or inpatient settings. Investigators searched Ovid MEDLINE, Elsevier Embase, and Ovid PsycInfo from December 2002 through December 2022 for relevant literature. Eligibility criteria included adults 50 years of age or older at increased risk for recurrent or persistent distress behaviors who live in long-term residential or inpatient care settings, are transitioning between healthcare settings and home, or reside in inpatient mental health settings. Eligible interventions primarily targeted healthcare workers (HCWs) or a healthcare team as the primary point of intervention activities, with the intent to change the way care is delivered to reduce or prevent distress behaviors.

Summary of Findings

Novel interventions designed to reduce distress behaviors among older adults with behavioral care needs that feature both HCW education and training, along with patient management intervention activities, have beneficial impacts on patient quality of life, reduction in the use of antipsychotics, and possibly distress behaviors. Less complex interventions, for example those focusing on HCW education only, appear less likely to lead to desired effects. However, more effective complex interventions raise questions about the challenges of high-fidelity implementation across varied long-term care settings for patients with distress behaviors. Work remains to be done to determine the impact of these interventions on healthcare staff outcomes, such as burnout, and system-level outcomes, such as utilization.

Additional findings:

• The vast majority of the literature (43 studies) examined interventions in the long-term residential care setting (e.g., nursing homes) among patients with dementia, and the largest number of studies evaluated interventions focused on developing HCW skill sets and knowledge alongside structured patient care activities.
• Seventeen interventions included both HCWs and patient-focused activities. Effects of these interventions were associated with a significant reduction in the odds of antipsychotic use and improvement in quality of life, but they were inconclusive for agitation.
• Six studies across multiple intervention types examined staff-level outcomes and none demonstrated a beneficial effect.
• None of the included studies reported healthcare use outcomes.

Limitations

The majority of included studies focused on care for patients with dementia in long-term care settings. While this field is at the forefront of managing distress behaviors, there are likely strategies and interventions being used in other settings (i.e., inpatient general medicine) that could be applied across patient populations that have not made it into the published peer-reviewed literature. Moreover, the interventions were almost universally complex in nature, combining components directed at multiple behaviors and clinical practices. Therefore, it was not possible to identify which specific individual intervention components (i.e., antipsychotic medication review or individualized care planning) were most effective.

Implications for VA

Findings from this review point to the importance of multi-level interventions with activities that target healthcare team members, patient evaluation and management, and, likely, environmental or policy structures. This is in keeping with recent trends in care for older adults with cognitive impairment that call to enhance the quality and efficiency of care, caregiver training, and interdisciplinary longitudinal care.

However, complex interventions require addressing real-world contextual factors at the time of implementation. Contextual factors such as staffing shortages, space restrictions, and fluctuating competing demands require time and resources to ensure successful, high-fidelity adoption of programs to reduce distress behaviors. This is particularly relevant across community-based long-term care facilities with widely varying levels of resources. VA expertise in implementation science could be leveraged to explore how to deliver multi-level interventions to reduce distress behaviors among older adults in the future.

Future Research

Areas of potential focus for future investigation include exploring these interventions in specific patient populations, clearly articulating the mechanism of action of these interventions, and consistently measuring staff outcomes. One specific population that warrants focused exploration of the effect of interventions to reduce distress behaviors is aging Veterans with PTSD, which can accelerate cognitive decline and may increase distress behaviors. It is important to explore how patients with different types of distress behaviors and health histories, such as those with PTSD, might respond differently to such interventions.

Investigators found that the existing literature did not always clearly articulate the intended mechanism of action, which makes it hard to determine if interventions are effective – or if the wrong outcome might have been measured. Better descriptions of how a given multi-level intervention is expected to reduce distress behaviors will be critical. Finally, distress behaviors among older adults are challenging for staff in healthcare settings. Consistent measurement of interventions’ impact on staff is important if that is a goal of intervention uptake. However, when the goal is improving staff outcomes such as burnout, higher system-level targets such as relationships with system leadership and work culture will likely need to be explored.  

Shepherd-Banigan M, Ramos K, McDermott C, et al. Health Care Team Interventions for Older Adults with Distress Behaviors: A Systematic Review. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2023.

To view the full report, go to: vaww.hsrd.research.va.gov/publications/esp/older-adults-distress-behaviors.cfm (Intranet only).

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management Brief is provided to inform you about recent HSR findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR Resource Center charged with disseminating important HSR findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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