A transformation in the treatment of patients with dementia is quietly taking place at the Lakeside Medical Unit at Johns Hopkins Bayview Medical Center.
There, as part of a collaboration with researchers at the Hopkins School of Nursing (JHUSON), clinicians are putting into practice a protocol that can ease the most troublesome symptoms of dementia, not through drugs but with behavior therapy.
The Tailored Activity Program, called T.A.P. for short, is a research effort led by Laura N. Gitlin, PhD, and project manager Katherine Marx, PhD, MPH, in the Center for Innovative Care in Aging at JHUSON, and collaborator Kimberly Van Haitsma, PhD, of the Polisher Research Institute. The goal is to treat dementia’s neuropsychiatric symptoms—of which agitation is the most disabling and frequently occurring—without medication. At Lakeside, a clinical team led by Dana Alonzi, OTR/L, has used the T.A.P. approach with significant success.
Agitation in persons with dementia increases health costs, reduces quality of life, burdens caregivers, can accelerate the disease, and often leads to hospitalizations and nursing home placement. And in a group setting of persons with dementia, one patient’s agitation can quickly spread to others. Treatment with medications can be at best modestly effective, carries serious risks, and may not reduce caregiver stress.
Alonzi and her team had been informally studying alternative treatment options, and T.A.P. seemed a perfect way for the three occupational therapists, two recreational therapists, and two geriatric nursing assistants to put those pieces together. “Our approach with the patients on the Lakeside Medical Unit wasn’t unlike T.A.P. in concept,” says Alonzi, clinical coordinator for the inpatient rehabilitation program. “But we spent a year formalizing a protocol and standardizing the methods with Dr. Gitlin and her team, which makes it different and more substantial.”
Under the program, activities are designed to match the patient’s interests and cognitive and physical abilities to help keep the person meaningfully engaged. The research is suggesting that this can minimize or prevent agitation. In the study, certified nursing assistants and recreational therapists were trained to use the tailored activities. The next step is to help the nursing staff use non-drug strategies as part of routine care on the unit.
“This clinical-based feasibility study is a great example of how research can be responsive to clinical needs and then impact practice and vice versa. It also shows the value of forming academic-clinical teams to improve care,” Gitlin says of the collaboration.
Elsewhere, the National Institute on Aging has funded a randomized trial using T.A.P. to help caregivers and families address behavioral challenges at home. Gitlin, the principal investigator, and co-investigators Nancy Hodgson, PhD, RN, Constantine Lyketsos, MD, MHS, and Quincy Miles Samus, PhD, report that a pilot phase “showed clinically meaningful and statistically significant reductions in agitation, with no adverse effects.”
T.A.P., also being studied in the Veterans Administration at Gainesville, FL, Scotland, Australia, and Brazil, is but one part of the groundbreaking work of the Center to treat depression, dementia, and disability in effective and often inexpensive ways.
Aging on Their Own Terms
Community Aging in Place–Advancing Better Living for Elders (CAPABLE) is a community outreach research project led by Sarah Szanton, PhD, CRNP. The study involves an occupational therapy, nurse, and home repair team that provides low-income older adults with resources to help them age safely in their homes. Often, something as simple and inexpensive as lowered shelves or a more secure banister can make the difference in a person being able to stay at home or having to relocate.
The success of CAPABLE has earned the attention of national media, from CBS and NPR to the Associated Press and others. "Very small changes can make a big difference," Szanton told NPR. "We're not saying, 'What's your blood pressure?' We're focusing on function: What do they want to do?"
Beat the Blues
Two studies by Center faculty recently showed that a low-cost, home-based program called Beat the Blues can reduce symptoms of depression in two of three older African Americans, even among those with severe financial worries.
In the August 2013 Annals of Internal Medicine, Gitlin and colleagues reported that 67 percent of Beat the Blues participants—primarily unemployed older women, living alone and experiencing financial and multiple health problems—showed meaningful reductions in depressive symptoms at four months. Szanton, Gitlin, and a colleague also found that Beat the Blues decreases depression even in financially strained older African American adults (August 2013 American Journal of Geriatric Psychiatry).
“Beat the Blues can help lift symptoms of depression among low-income, older African Americans and it has potential for success in other populations,” Gitlin says.
Alzheimer’s Info for All (CNE for Some)
Through their first massive open online course (MOOC), Care of Elders with Alzheimer's Disease and Other Major Neurocognitive Disorders, Hodgson and Gitlin will explore the latest knowledge and global approaches in dementia care. The five-week course is open to anyone, but nurses registering for the free course can earn Continuing Nursing Education (CNE) credits at a small additional cost ($99). The MOOC—on the openware course platform Coursera—begins October 14.
Johns Hopkins is one of the first universities to offer CNE credits for a MOOC. Registration is now open.
These programs are co-provided by the JHUSON and the Institute for Johns Hopkins Nursing (IJHN). IJHN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center (ANCC) Commission on Accreditation. CNE activities are learning activities intended to build upon the educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to the end of improving the health of the public and RN’s pursuit of their professional goals.