Caregivers of persons with dementia (PWD) are often responsible for their loved one's daily care coordination and provision. Eighty percent of PWD have behavioral or psychological disturbances, including 40% that are aggressive behaviors. Aggressive behaviors are perhaps the most problematic disturbances because they lead to increased institutionalization, injuries, and use of antipsychotic medications;yet few interventions for aggressive behavior are available. Innovative preventive approaches are urgently needed to replace the use of tranquilizing medications because of their associated increased mortality and morbidity in PWD. The prevalence of pain in PWD is about 60%, and it is a strong predictor of aggression. The biopsychosocial model of pain posits that pain is bidirectionally related to psychological factors (ie, depression) and social support factors (i.e., quality of caregiver/PWD relationship) in addition to biological factors. Thus, depression and quality of the caregiver/PWD relationship can be seen as pain-related features. Caregivers are ideally suited to help address pain, depression, and the caregiver/PWD relationship, thus preventing the development of aggression;but they need tools to assist them in identifying and managing these symptoms. The objectives of this proposal are to assess whether this caregiver intervention, Aggression Prevention Training for Caregivers of Individuals with Dementia (APT), 1) decreases incidence of aggression, 2) decreases aggression-related outcomes (nursing-home placement, caregiver burden, positive aspects of caregiving, and behavior problems), and 3) decreases pain and pain-related features (depression, caregiver/PWD relationship difficulties). This 5-year randomized controlled trial based on the Unmet Needs Model will focus on preventing aggression in PWD with pain and pain-related features by providing the caregiver with targeted education and skill training. PWD and their caregivers will be randomized to APT or to an enhanced usual primary care condition (EU-PC). APT will use active learning tools, including didactics, role- playing, and multimedia (eg, books and DVDs) to educate and provide skill training for the caregiver. The 6-8 modules in the intervention will include 4 core modules that address 4 main aggression risk factors: a) recognizing pain, b) treating pain, c) increasing pleasant activities, and d) improving patient-caregiver communication. Caregivers can select 2 to 3 additional elective sessions;elective selection is guided by the needs of the dyad to further enhance skills related to these core topics. EU-PC provides the patient and caregiver educational materials on pain, notifies the primary care provider of the PWD's level of pain and depression, and provides 8 weekly supportive telephone calls to caregivers. PWD and caregiver outcomes will be collected at baseline, 3, 6 and 12 months. Data analysis will include both univariate descriptive statistics and inferential statistics, including regression models, repeated measure modeling and Cox proportional hazards models.
Prior studies of aggression treatment have not examined using a preventive strategy to decrease incidence of aggression in persons with dementia (PWD). Almost all studies have examined use of pharmacologic interventions following development of aggression. This 5-year randomized controlled trial based on the Unmet Needs Model will focus on preventing aggression in PWD with pain and pain-related features (i.e., depression, patient/caregiver relationship problems) by providing the caregiver with targeted education and skill training.