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IIR 09-351 – HSR&D Study

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IIR 09-351
Preventing Aggression in Veterans with Dementia
Mark E. Kunik MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: May 2011 - September 2015

BACKGROUND/RATIONALE:
Dementia is one of the most costly chronic conditions that VA treats (Dementia Steering Committee, 2008). In 2008, 175,621 VA patients had a diagnosis of dementia, and the prevalence will increase to 2017 when the prevalence is expected to peak (VHA Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, 2004). Although dementia is primarily defined by memory disturbances, many of the financial and psychosocial costs are associated with its frequent concurrent medical disorders and psychological/behavioral disturbances. The 2008 Dementia Steering Committee recommended that the VHA fund more research on non-pharmacologic interventions to address behavioral disturbances that occur in 90% of persons with dementia. The investigators for this study have a sustained record of scientific findings that point to the urgent need to find new approaches to address aggression, which occurs in 40% of veterans with dementia and often is not addressed (Kunik et. al. 2007), leading to increased institutionalization, injuries, and use of antipsychotic medications. An earlier HSR&D project (IIR 01-159), Causes and Consequences of Aggression in Persons with Dementia, found that pain was the strongest predictor of aggression. The prevalence of pain in persons with dementia is known to be 30-50% (Sawyer et. al., 2006).

No medications are efficacious in the treatment of aggression in persons with dementia. However, antipsychotic medications are still commonly prescribed, despite lack of efficacy and black box warnings of the increased mortality and morbidity associated with these medications in persons with dementia. Innovative approaches are urgently needed to replace the model of treating aggression with tranquilizing medications. We propose an intervention that is innovative in that it aims to prevent the development of aggression in dementia patients with pain, and is guided by empirical evidence regarding mutable risk factors for aggression.

OBJECTIVE(S):
The objectives of this proposal are to assess whether an psychoeducational intervention, Preventing Aggression in Veterans with Dementia: 1) decreases incidence of aggression, 2) decreases pain, 3) decreases caregiver burden and improves caregiver-patient relationship, and 4) decreases injuries, use of antipsychotic medication, and nursing home use.

METHODS:
Preventing Aggression in Veterans with Dementia (PAVeD) is a randomized controlled trial of a modular, home-based, 6-8 session psychoeducational intervention delivered to caregiver-patient dyads. We will recruit 220 patients with mild to moderate dementia and pain who receive care in primary care clinics. Patients will be randomized to the PAVeD intervention or to enhanced usual care. The active intervention will include core modules that address the recognition and treatment of pain, improving caregiver-patient communication, and increasing patient activity levels. Additional modules offer further skills training in these three core areas, and will be selected according to the needs and preferences of the dyad. The enhanced primary care control condition will include providing educational materials on dementia and pain, notifying the primary care provider of the patient's level of pain, and six weekly supportive telephone calls to caregivers.

FINDINGS/RESULTS:
Primary Outcome: There were no significant differences in aggression (primary outcome) incidence between intervention and control groups; however, the PAVeD group had significantly better mutuality than controls. Mutuality was the sole secondary outcome significantly different between treatment groups. The nature of the PAVeD intervention likely increased mutuality by positively impacting multiple factors closely associated with mutuality (e.g., improving communication) which created a significant difference in mutuality between treatment groups. This finding is promising because mutuality is a powerful predictor of psychosocial well-being between caregivers and PWD and, thus, PAVeD has demonstrated itself as an effective intervention in positively impacting the relationship between the patient-caregiver dyad.

Secondary findings examining pain recognition and treatment in persons with dementia:
Recognition
Pain assessment was documented for 98% or persons with dementia and a standard pain scale used for 94%. Modified pain scales were rarely used. Though 70% self-reported pain of "quite bad" or worse, charts documented no pain in 64%. When pain was identified, treatment was offered to 80%; but only 59% had a follow-up assessment within 6 months. Nonpharmacological interventions were underused.

Treatment
Only pain diagnoses were associated with greater
participant-reported pain. Depressive symptoms, mental
health diagnoses, and level of functional ability were not associated
with participant-reported pain, demonstrating that
community-dwelling adults with dementia can experience pain
in the absence of mood and/or functional disturbances. As such,
these factors may not be accurate heuristics for self-reported
worst pain in this population.


IMPACT:
This intervention that was designed to prevent the development of aggression in persons with dementia, did not show differences from control. However, the study does add to literature on the need to improve recognition and treatment of pain in persons with dementia.

PUBLICATIONS:

Journal Articles

  1. Thakur ER, Amspoker AB, Sansgiry S, Snow AL, Stanley M, Wilson N, Freshour J, Kunik ME. Pain Among Community-Dwelling Older Adults with Dementia: Factors Associated with Undertreatment. Pain medicine (Malden, Mass.). 2017 Aug 1; 18(8):1476-1484.
  2. Amspoker AB, Hersch G, Snow AL, Wilson N, Morgan RO, Sansgiry S, Kunik ME. A Psychometric Evaluation of the Pleasant Events Schedule-Alzheimer's Disease (Short Version): Among a Veteran Population. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2019 May 1; 38(5):673-693.
  3. Kunik ME, Snow AL, Wilson N, Amspoker AB, Sansgiry S, Morgan RO, Ying J, Hersch G, Stanley MA. Teaching Caregivers of Persons with Dementia to Address Pain. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2017 Feb 1; 25(2):144-154.
  4. Li J, Snow AL, Wilson N, Stanley MA, Morgan RO, Sansgiry S, Kunik ME. The Quality of Pain Treatment in Community-Dwelling Persons with Dementia. Dementia and geriatric cognitive disorders extra. 2015 Sep 1; 5(3):459-70.
  5. Breland JY, Barrera TL, Snow AL, Sansgiry S, Stanley MA, Wilson N, Amspoker AB, Kunik ME. Correlates of pain intensity in community-dwelling individuals with mild to moderate dementia. American journal of Alzheimer's disease and other dementias. 2015 May 1; 30(3):320-5.
  6. Fowler JH, Dannecker K, Stanley M, Wilson N, Snow AL, Kunik ME. Preventing aggression and other secondary features of dementia in elderly persons: Three case studies. Bulletin of The Menninger Clinic. 2015 Jan 1; 79(2):95-115.
  7. Bradford A, Shrestha S, Snow AL, Stanley MA, Wilson N, Hersch G, Kunik ME. Managing pain to prevent aggression in people with dementia: a nonpharmacologic intervention. American journal of Alzheimer's disease and other dementias. 2012 Feb 1; 27(1):41-7.
Conference Presentations

  1. Kunik ME. Strategies to Prevent Aggression in Persons with Dementia. Paper presented at: University of Oklahoma Health Science Center Monthly Seminar; 2015 Apr 23; Oklahoma City, OK.
  2. Kunik ME. Preventing Aggression in Veterans with Dementia. Poster session presented at: American Association for Geriatric Psychiatry Annual Meeting; 2015 Mar 27; New Orleans, LA.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care, Neurodegenerative Diseases
DRE: Prevention
Keywords: Caregiving, Dementia, Home Care, Pain
MeSH Terms: none

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