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Focus on Alzheimer's Disease and Related Disorders

Cognizance of Cognition in Older Primary Care Patients With Depression and Restraining Restraint and Agitation in Nursing Home Residents With Dementia

Eric M. Reiman, MD

Published: January 15, 2010


Cognizance of Cognition in Older Primary Care Patients With Depression and Restraining Restraint and Agitation in Nursing Home Residents With Dementia

Late-life depression is a formidable problem in its own right. Could it also be a harbinger of cognitive decline and dementia? Several studies support that "depressing" forecast, while other studies do not. In this section of Focus on Alzheimer’s Disease and Related Disorders, Boyle and colleagues report an association between the diagnosis of major depressive disorder or minor depression in older primary care patients and the onset of cognitive impairment and dementia over the next 3 years. Strengths of this study include its prospective cohort design, the use of clinical diagnoses to relate depression to the subsequent onset of cognitive impairment, and the recruitment of older patients from primary care offices, in which depression and cognitive impairment are common but underrecognized clinical presentations.

As the authors note, additional research is needed to confirm the study’s findings, overcome several limitations, and clarify the nature of the relationship between late-life depression and the subsequent onset of cognitive decline. While the diagnosis of late-life depression should not cause patients undue alarm about their risk of cognitive decline, it gives clinicians one more reason to monitor their older patients for cognitive impairment and dementia and to manage these conditions accordingly.

There is an urgent need for nonpharmacologic strategies to increase quality of life and care in nursing home residents with dementia and a commensurate need for rigorous scientific studies to demonstrate their value. In this issue, Testad and colleagues compared 2 Norwegian nursing homes participating in a 2-day education and 6-month group guidance program for their staff members to 2 nursing homes receiving usual care in terms of the dementia residents’ aggression, the staff members’ use of restraints, and the use of antipsychotic medications.

The education and training program was associated with a significantly greater reduction in the residents’ severity of aggression after 6 and 12 months, a significantly greater reduction in the use of restraint in the staff members’ resident interactions after 6 but not 12 months, and no significant differences in the use of antipsychotic medications. Strengths of this study include the use of patient-centered and clinically meaningful outcome measures, the participation of all staff members in the nursing homes assigned to the active intervention, blinded assessment procedures, and the effort to assess the sustainability of benefits after intervention was concluded.

As the authors note, one cannot exclude the possibility that their findings were attributable to the confounding effects of baseline differences in the aggression and restraint use or to nonspecific effects of the intervention on staff member attention or group activity. Still, this study supports the promise of staff member education and training programs for the reduction in nursing home resident aggression and restraint use and the possible need for continuous staff supervision to sustain the benefit in restraint use. It provides further support for the development and scientifically rigorous assessment of nonpharmacologic strategies to improve the quality of life and care of dementia patients in nursing homes.

Eric M. Reiman, MD

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