Table 2.
Narrative summary of characteristics for included studies
| Author | Country | Setting | Sample size (N) | Age in years mean (SD) | Intervention | Control group | Duration/ follow-up | Dementia severity | Outcome measuresb |
| RCTs | |||||||||
| Ballard et al. [62] | UK | Nursing home | 847 | 88.5 (0.50) | The WHELD program, which combined: | TAU | 9 months | FAST stage: | Primary: |
| 1) staff training (training in PCC for staff and promoting tailored person-centered activities and social interactions), 2) social interaction, and 3) guidance on use of antipsychotic medications | Mild or less | - QoL (DEMQOL-Proxy) | |||||||
| TAU: 35 (7.90%) | Secondary: | ||||||||
| WHELD: 47 (11.64%) | - Agitation (CMAI) | ||||||||
| Moderate | - NPS (NPI-NH) | ||||||||
| TAU: 38 (8.58%) | - Antipsychotic use (Med. charts) | ||||||||
| WHELD: 39 (9.65%) | - Global deterioration (CDR) | ||||||||
| Moderately severe | - Mood (CSDD) | ||||||||
| TAU: 267 (60.27%) | - Unmet needs (CANE) | ||||||||
| WHELD: 241 (59.65%) | - Mortality | ||||||||
| Severe | - Quality of interactions (QUIS) | ||||||||
| TAU: 103 (23.23%) | - Pain (APS) | ||||||||
| WHELD: 77 (19.06%) | - Cost | ||||||||
| Chenoweth et al. [64] | Australia | Urban residential sites | 289 | DCM: 83 (7.6) PCC: 84 (6.4) UC: 85 (6.6) | DCM: 2 healthcare professionals at each site were trained to become certified mappers in a 2-day course. The remaining staff was trained by the certified mappers and applied PCC plans. Additional support was provided via regular telephone support from experts in DCM. PCC: Bradford University training manual was applied in a 2-day training session for staff, central to the practices was a careful review of residents’ life histories. | UC, characterized by custodial and physical task-oriented practices | 4 months Follow-up: 4 months | GDS, mean (SD) DCM = 5,6 (1,3) PCC = 5,6 (0,73) CAU = 5,3 (1,1) | Primary: - Agitation (CMAI) |
| Secondary: | |||||||||
| - NPS (NPI-NH) | |||||||||
| - QoL (QUALID) | |||||||||
| - Falls (Records)c | |||||||||
| - Use of antipsychotic drugs (Records) | |||||||||
| - Use of physical restraint (QUIS) | |||||||||
| - Cost of treatment | |||||||||
| Chenoweth et al. [63] | Australia | Residential aged care homes | 601 | CAU = 86 (7) PCC = 84 (8) PCE = 84 (8) PCC + PCE = 84 (7) | PCC: Five staff from each of the 19 PCC homes received 32 hours off-site training, which focused on paying attention to the residents’ feelings when agitated, interacting with residents in a person-centered way and using person-centered care planning to meet the residents’ psychosocial needs, followed by on-site supervision in these processes (range 2–16 hours) and telephone support. These staff trained remaining staff after completion of their own training. PCE: Included improvements to the safety, accessibility and utility of outdoor spaces, provision of a greater variety of social spaces and using color and objects for way-finding and to improve feelings of familiarity. Two experts in PCE principles planned and supervised implementation of recommended PCE interventions with a maximum budget of AUD$10,000 per home. | UC and UE | 4 months, FU: 8 months | GDS severe/very severe in %UC = 88 PCC = 90 PCE = 82 PCC + PCE = 85 | Co-primary outcomes: - QoL (DEMQoL self-report and proxy interview) - Agitation (CMAI)d - Emotional responses in care (ERIC)e - Depression (CSDD) Secondary outcome: - Care interaction quality (QUIS)e |
| Cohen-Mansfield et al. [65] | USA | Nursing homes | 231 | TREA: 85.9 (8.62) Control: 85.3 (9.62) Total: 85.7 (8.89) | TREA including individually tailored non-pharmacologic interventions (e.g., simulated social contact, magazine/reading/book on tape (audio drama), music, physical activities, sensory stimulation, puzzles and games, sorting, videos and television, group activities). Delivered by research team (experts in gerontology and psychology). | Placebo intervention (in-service education for care staff members about the syndromes, etiologies, and possible non-pharmacological treatments for agitation). | 2 weeks | MMSE Mean (SD) TREA: 7.62 (6.33) Control: 9.38 (6.76) Total = 8.12 (6.48) | Primary: - Agitation (ABMI) Secondary: - Observed affect (Lawton’s Modified Behavior Stream) |
| Eritz et al. [66] | Canada | Nursing homes | 73 | 85.98 (7.49) | Life history intervention: Each history, derived from proxy (majorly children and spouses) interviews, was approximately two pages, including one page of photographs, shown to care staff. Family members were encouraged to submit resident’s photographs as well as artefacts from the past to be included. The residents’ life histories or medical histories were written by the primary researcher or a trained research assistant. | Medical history (CAU) | 3 months | Average CPS-score (SD): 4.17 (1.57) | - Aggression (ABS) - Agitation (CMAI) - QoL (ADRQL-R) |
| Fossey et al. [67] | UK | Nursing homes | 349 | Control: 82 (53-101)* Intervention: 82 (60-98) | PCC-staff training including an intervention package: care staff were trained in the philosophy and application of PCC. This included ongoing training and group supervision with support and feedback by researchers. | CAU | 10 months | CDR, n (%): None, questionable, or mild Control: 37/163 (23) Intervention: 25/170 (15) Moderate Control: 32/163 (20) Intervention: 46/170 (27) Severe Control: 94/163 (58) Intervention: 99/170 (58) | Primary: - Neuroleptic use and dose of neuroleptic Secondary: - Agitation (CMAI) - Quality of life - Proportion of patients taking other psychotropic drugs (Med. records) - Adverse events (including documented falls) (Med. records) - Incidents involving irritable behavior directed at staff or other residents |
| Lawton et al. [68] | USA | Nursing homes | 182 | N/A | The “stimulation-retreat” model: The intervention program attempted to modulate different perspectives by acknowledging various needs for stimulation both across individuals and at different times within the same person. The major treatment task was to be sensitive to individual preference, individual capability, and contextual appropriateness. The major components of the program were staff training, interdisciplinary care planning, family support, and activity programming, with the choice of a specific type of one-to-one contact being determined by consensus at the care planning session; the most frequent types of contact were conversation, music, reading, or looking at pictures with the resident. | No further information except from “controls”. | 12 months | GDS, mean Total (baseline) = 5.53 Total (FU) = 5.87 | - Cognitive status (MDRS, GDS) - Functional health (PSMS) - Negative behaviors (BEHAVE-AD) - Agitation (CMAI) - Affective states (incl. depression, externally engaging behaviors) (MOSES) - Externally engaging behaviors (MOSES, Behavior Rating Scale, Activity Participation Scale) - Behavior streams (The Psion event recorder, The Observer, PGCARS,) - Composite factor scores for Problem Behaviors, Depression, Social Quality, and Time Use (MDS) |
| Rokstad et al. [69] | Norway | Nursing homes | 624 | Total: 85.7 (8.3) DCM: 85.1 (8.7) VPM: 85.1 (8.5) Control: 87.0 (8.3) | DCM: From each participating ward in the intervention group, two care staff attended a DCM course and became certified mappers. The remaining staff were trained in PCC with lectures by the researchers. The certified staff conducted the mapping and trained the remaining staff members. Feedback sessions occurred during the intervention period. VPM: From each participating nursing home, two nurses were appointed as VPM coach including the attendance of a VPM-training course. The VPM coaches trained the remaining staff with lectures applying the VPM manual [97]. | Placebo incl. DVD with lectures about dementia (no information about PCC) + CAU. | 10 months | CDR, mean sum of boxes (SD) Total: 12.8 (4.1) DCM: 12.4 (4.0) VPM: 13.5 (4.4) Control: 12.4 (3.9) | Primary outcome: - Agitation (BARS) Secondary outcomes: - NPS (NPI-Q), - Depression (CSDD)f - QoL (QUALID)g |
| Sloane et al. [70] | USA | Nursing homes | 73 | Control: 86.9 (6.1) Intervention: 86.0 (8.6) | Person-centered showering sought to individualize the experience for the resident by using a wide variety of techniques, such as providing choices, covering with towels to maintain resident warmth, distracting attention (e.g., by providing food), using bathing products recommended by family and staff, using no-rinse soap, and modifying the shower spray. The towel bath is an in-bed method in which the caregiver uses two bath blankets, two bath towels, a no rinse soap, and 2 quarts of warm water; keeps the resident covered at all times; and cleanses the body using gentle massage. | Usual methods of showering | 3 months | MMSE, mean (SD): Control: 2.1 (4.1) Intervention: 2.2 (4.0) | Primary outcomes: - Agitation (CAREBA, The Observer Video-Pro) - Aggressive behaviors (CAREBA, The Observer Video-Pro) - Discomfort (Modified discomfort scale for dementia of the Alzheimer type) Secondary measures of effect: - Bath duration and completeness (the number of body parts bathed and the number of minutes spent being bathed) - Skin condition (Hardy Skin Condition Data Form) - Skin microbial flora (Skin Cultures) |
| Testad et al. [71] | Norway | Nursing homes | 274 | - Intervention: 88.2 (8.2) Control: 85.2 (8.2) | The "Trust Before Restraint" intervention was based on the evidence of the Relation Related Care (RRC) intervention and decision-making process (DMP), the Norwegian legislation on restraint and best practice for PCC. Included elements of shared decision making and a life history/bibliographical approach. | TAU | 7 months | CDR, sum of boxes mean (SD) Intervention: 12.2 (4.8) Control: 12.6 (4.2) | Primary outcomes: - Use of restraint (standardized interview) Secondary outcomes: - Agitation (CMAI, NPI) - Use of psychotropic drugs (Medical Journals) |
| Van Bogaert et al. [72] | Belgium | Nursing homes | 72 | Total: 84 (78–90)** Intervention: 84 (79.5–90.5) Control: 84 (76–89) | SolCos transformational reminiscence model was performed by trained nursing home volunteers as facilitators. | CAU | 10 weeks | MMSE: Intervention: 18 (15–22)** Control: 15 (12.5–20) | Primary outcomes: - Depression (CSDD) Secondary outcomes: - Cognition (MMSE, FAB) - Behavior (NPI) |
| van de Ven et al. [73] | The Netherlands | Nursing homes | 268 | Intervention: 84.6 (6.1) Control: 83.5 (6.6) | DCM: two staff from each care home receiving the intervention were trained and became certified mappers. Initially, an external expert delivered a lecture on PCC. Subsequently, the certified staff conducted the mapping and trained the rest of the staff members. In the beginning of the intervention, members of care staff were given a lecture in both DCM and PCC. | CAU | 4 months, FU 8 months | N/A | Primary outcomes: - Agitation (CMAI) Secondary outcomes: - NPS (NPI-NH) - QoL (Qualidem, EQ-5D) |
| van der Ploeg et al. [74] | Australia | Residential facilities | 57 | Total: 78.1 (9.8) | Personalized one-to-one activities that were delivered by a trained psychologist and higher degree psychology student applying Montessori principles. Typical selections included listening and singing along to favorite music, looking at and sorting pictures, arranging flowers, sorting dry pastas, folding towels, screwing nuts and bolts together, planting seeds, and making puzzles. | Placebo: social interaction via general conversation | 4 weeks | MMSE (range = 0–23) Mean (SD): 6 (8) | Primary outcomes: - Agitation (direct observation and count of frequency of agitated behaviors) Secondary outcomes: - Affect (PGCARS) - Engagement (MPES) |
| Van Haitsma et al. [75] | USA | Nursing homes | 195 | Total: 88.7 (64–105)**** | Individualized Positive Psychosocial Intervention (IPPI): The intervention offered five basic types of activities reflective of the most common resident-preferences. Within each category, two or more specific options were offered (30 activity options total). Physical exercise included the option to take an outdoor walk or work with clay. Music included singing or listening to a favorite artist; reminiscence, reviewing family photos, or writing letters; ADLs, manicures, or preparing a snack; and sensory stimulation could mean a hand massage with lotion or smelling fresh flowers. | UC + attention control | 3 weeks | MMSE (range 0–24), mean (SD) Total: 9.0 (7.6) | - Negative affect (sadness, anger, anxiety) - Positive affect (pleasure, alertness) - Verbal behaviorh (very negative, negative, positive, very positive, no verbal) - Nonverbal behavior (psychosocial task, restlessness, null behavior, eyes closed, aggression, uncooperative, positive touch)h Outcome measures were collected through direct observations in the form of 10-min “behavior streams”, using The Psion event recorder and The Observer software. |
| van Weert et al. [76]a | The Netherlands | Nursing homes | 129 | Intervention: 84.01 (8.7) Control: 82.60 (8.2) | Staff was trained in principles of Snoezelen. The training focused in particular on: the development of CNAs awareness of the residents’ physical, social and emotional needs, making contact with demented residents and showing affection and empathy, supporting demented residents in responsiveness, avoiding to correct the residents’ subjective reality, avoiding to spread useless cognitive information and to test the residents’ remaining cognitive knowledge. The training paid attention to practical skills needed for the application of multi-sensory stimulation, such as taking a life style history interview with family members, arranging a stimulus preference screening to find out which sensory stimuli the resident likes most and writing a snoezel care plan describing how to approach the resident and how to integrate multi-sensory stimuli in 24 h care. | Usual care | 18 months | BIP7; 0–21***, mean score (SD) Intervention: 14.61 (3.1) Control: 13.37 (4.0) | - Communicative behavior (RIAS) - Nonverbal behavior, e.g., gazing, affective touch, smiling (Observation Scheme with Indicators) |
| Boersma et al. [77] | The Netherlands | Nursing homes | 212 | Intervention: 85.3 (7.5) Control: 85.9 (7.8) | Veder Contact Method (VCM): VCM aims to stimulate contact between the person with dementia and the caregiver, by using theatrical, poetic and musical communication in combination with elements of existing care methods, that is, reminiscence, validation, and neurolinguistics programming. Care staff were trained in VCM. | CAU | 9 months, FU 3 months | MMSE, mean (SD) Intervention: 13.9 (8.9) Control: 14.6 (7.3) | - QoL (QUALIDEM) - Behavior and interactions (INTERACT) - Mood (FACE, a three-point Likert scale) DCM to collect observational data on residents and caregivers. |
| Tay et al. [78] | Singapore | Hospital, Dementia Specific Care Unit | 230 | Intervention: 82.45 Control: 84.37 | CAMIE: (1) enhanced medical care protocol, which includes moderating intrusive interventions, a physical restraints-free policy, appropriate and modest use of psychotropic medications, careful attention to hydration, bowel and bladder care, and encouraging mobilization and (2) enhanced psychosocial care protocol, which includes prioritizing patient needs over tasks, encouraging family members and volunteers to provide companionship, and engaging in daily structured activities (e.g., music therapy, recreational/group activities). CAMIE is run by a multidisciplinary team of doctors, nurses, and allied health professionals including a social worker, dietician, pharmacist, as well as physio, occupational, and speech and music therapists. | Conventional geriatric ward | 6 months | DSM-IIIR, n and %Mild Intervention: 14 (8.20) Control: 2 (3.30) Moderate Intervention: 102 (60.00) Control: 37 (61.70) Severe Intervention: 54 (31.80) Control: 21 (35.00) | - Well-being (WB- and IB-Score) - Functional ability (MBI) - QoL (EQ-5D Index Score) - Agitation (PAS) - Use of psychotropic medications (Medical records) - Length of stay - Cost-effectiveness |
| Verbeek et al. [79] | The Netherlands | Long-term institutional nursing care (i.e., small-scale living facilities and traditional psychogeriatric wards) | 259 | Intervention: 82.4 (7.9) Control: 83.1 (6.5) | SSLF: These facilities were selected based on six characteristics: (1) eight residents per house or unit at most; (2) daily household duties were centered around activities of daily life; e.g., all meals were prepared in the unit’s kitchen by nursing staff together with the residents and/or their family caregivers; (3) staff performed integrated tasks: alongside medical and personal care, they also carried out household chores and organized activities; (4) a small consistent team of staff took care of the residents; (5) daily life was largely determined by the residents, family caregivers, and nursing staff; and (6) the physical environment resembled an archetypal house SSLF are based on a care concept, which emphasizes the normalization of daily life, encourages residents’ participation and autonomy, and a person-centered attitude towards care. | Traditional psychogeriatric wards | 12 months incl. FU | MMSE (0-30), mean (SD) Intervention: 11.1 (7) Control: 10.5 (6.6) | Outcome measures: - NPS (NPI-NH, CMAI) - Depression (CSDD) Additional variables: - Social engagement (Subscale ISE from RAI-MDS) - Use of physical restraint (Questionnaire, type and no. of times) - Psychotropic medication (Medical Journals) |
| Villar et al. [80] | Spain | Nursing homes | 52 | Total: 86.7 (7.3) | ICP program: Residents were invited to participate in ICP multidisciplinary meetings, attended by staff members (including doctors, nurses, psychologists, social workers and auxiliary CGs) who reached agreements on treatments and recommended intervention strategies. Staff were asked to welcome residents, orientate them in time and space, detail the goals of the meeting, address their interventions to them and take their perspective into account, explain the agreements reached and ask them for their opinion about the treatment and its implementation. | Usual care, i.e., care planning meetings without the patient. | 10 months | MMSE, mean (SD): 16.1 (4.0) | - QoL (GENCAT, proxy-measure) |
Abbreviations: ABMI, agitation behavior mapping instrument, ADRQL-R, Alzheimer’s Disease-related Quality of Life-Revised, APS, Abbey Pain Scale, BARS, Brief Agitation Rating Scale, BEHAVE-AD: Clinical Rating Scale for the Assessment of Pharmacologically Remediable Behavioral Symptomatology in Alzheimer’s Disease, BIP7, Dutch Behavior Observation Scale for Psychogeriatric In-patients Version 7, CANE, Camberwell Assessment of Need for the Elderly, CAU, Care as usual, CAMIE, Care for Acute Mentally Infirm Elders, CAREBA, Care Recipient Behavior Assessment, CDR, clinical dementia rating, CMAI, Cohen-Mansfield’s agitation inventory, CPS, Cognitive Performance Scale, CSDD, Cornell Scale for Depression in Dementia, DCM, Dementia Care Mapping, DemQOL, dementia quality of life, DSM-IIIR, Diagnostic and Statistical Manual of Mental Disorders, DVD, digital video disk, EQ-5D, European Quality of Life 5 Dimensions, ERIC, Emotional Response in Care, FAB, Frontal Assessment Battery, FACE, Face expression scale, FAST, functional assessment staging of Alzheimer’s disease, FU, Follow-up, GDS, Geriatric Depression Scale, GENCAT, Government of Catalonia Scale for Assessment of Residents’ QoL, ICP, Individualized care planning, INTERACT, Mood and Behavior of persons with dementia, ISE, Index of Social Engagement, MBI, Modified Barthel Index, MDRS, Mattis Dementia Rating Scale, MDS, minimum data set, MMSE, mini mental state exam, MOSES, Multidimensional Observation Scale for Elderly Subjects, MPES, Menorah Park Engagement Scale, NPI, Neuropsychiatric Inventory, NPI-NH, Neuropsychiatric Inventory–Nursing Home, NPI-Q, Neuropsychiatric Inventory Questionnaire, NPS, Neuropsychiatric Symptoms, NRS, Non-Randomized Studies, PAS, Pittsburgh Agitation Scale, PCC, Person-Centered Care, PCE, Person-Centered Environment, PGCARS, Philadelphia Geriatric Center Affect Rating Scale, PSMS, Physical Self-maintenance Scale, QoL, Quality of Life, QUALID, quality of life in late-stage dementia, QUALIDEM, Quality of Life of people with Dementia, QUIS, questionnaire for user interaction satisfaction, RAI-MDS, Resident Assessment Instrument –Minimum Data Set, RCT, Randomized Controlled Trial, RIAS, Roter Interaction Analysis System, SD, Standard Deviation, SSLF, Small-scale living facilities, TAU, Treatment as usual, TREA, Treatment Routes for Exploring Agitation, UC, Usual Care, UE, Usual environment, VIPS Framework, valuing people with dementia (V), individualized care (I), understanding the world from the patient’s perspective (P) and providing a social environment that supports the needs of the patient (S), VPM, VIPS Practice Model, WHELD, Improving Wellbeing and Health for People Living with Dementia.
*Median (range).
**Median (IQR).
***The underlined scores indicate the most favorable score (least impairment) for the scale.
****Mean (range).
aNote: van Weert et al. (2005) applied a quasi-experimental pre- and post-test design, including randomization, hence this study was assessed with RoB2 for risk of bias and is for consistency portrayed in the RCT-category of this table.
bSignificant effects are marked in bold.
cAt follow-up, there were fewer falls with DCM than with usual care (p = 0.02) and more falls with PCC than with usual care (p = 0.03).
dThose in PCC + PCE had non-significant changes.
eThe percentage of positive emotional responses to care (ERIC) improved significantly over time for the PCC + PCE group (by 7%on average, p = 0.01), but as the group-by-time interaction was not significant (0.07), differences among groups for emotional responses cannot be inferred. QUIS improvements did not occur in the other groups than PCC + PCE (group-by-time interaction p = 0.007).
fSignificant for VPM.
gSignificant for DCM. hMore negative verbal behaviors by AC- compared to UC or IPPI-groups. AC-group showed more positive behaviors than IPPI; AC- and IPPI-groups showed more positive behaviors than UC-group. The IPPI-group showed significantly more very positive responses than either UC- or AC-groups. Nonverbal responses were significantly higher for the UC-group compared to AC- and IPPI-groups.