Inside the Black Box: Culture Change and Behavioral Outcomes in Dementia
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DESCRIPTION (provided by applicant): PA-13-1356 (NIH R03 Small Grant Program) Critical to reducing the inappropriate use of antipsychotic drugs in nursing homes (NH) is the identification of nonpharmacologic interventions capable of decreasing the incidence and severity of behavioral and psychological symptoms of dementia (BPSD); certain practices aligned with the increas- ingly widespread NH culture change (CC) movement may offer such an intervention. Despite the U.S. Food and Drug Administration's (FDA) warnings, evidence of marginal effectiveness and dangerous side effects, and nearly 30 years of federal NH regulations targeting inappropriate use, an average of 1 in 5 NH residents in the U.S. are currently receiving antipsychotic drugs, and over 80% of these prescriptions are written for residents with dementia. Because dementia-related emotional distress may be moderated by certain environmental factors, it is possible that CC-aligned facility redesign, from institutionalto more "homelike settings", may serve as an unrecognized form of nonpharmacologic intervention for BPSD; however, we found no studies that have investigated this relationship in NH populations with dementia. We will use previously collected national CC survey data in 1,665 NHs merged with resident assessment and prescription drug data to investigate the following specific aims: 1) To examine the asso- ciation between extent of "homelikeness" in the physical environment and the incidence and severity of BPSD; and 2) To evaluate the relationship between the extent of "homelikeness" and the prevalence of antipsychotic drug use, in NH residents with dementia. Our central hypothesis is that greater degrees of CC-related environmental trans- formation will be associated with more favorable behavioral outcomes, and less prevalent use of antipsychotic drugs. The proposed research is significant, because it addresses a limiting factor in the wider adoption of CC initia- tives: the lack of a strong evidenc base to support the value of specific CC elements in terms of relevant resident- and facility-level outcomes; and it extends existing research in a new direction by examining relationships between a specific CC domain (homelike environment) and behavioral outcomes in NH residents with dementia. Ultimately, the results have the potential to improve palliative care of NH residents with dementia, by motivating the develop- ment of innovative approaches to decrease problematic use of antipsychotic drugs.
