...recruited residents two nursing homes for this study and randomly assigned them to AICT or to usual care (UC). They assessed the participants before and after the completion of AICT or UC and found that as compared with UC, the AICTs were effective in reducing agitated behavior and pain but not depression. This is one of few pioneering studies to examine the effectiveness of team care on the health and well-being of nursing home residents with advanced dementia. More research is needed about how to intervene effectively with this population and to overcome the methodological challenges associated with doing research on real-world clinical practice issues in busy and often understaffed nursing home settings.

KEY WORDS: dementia; interdisciplinary teams; intervention research; nursing home residents

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Dementia increases exponentially with age, and as longevity in the United States has increased, the incidence and prevalence of Alzheimer's disease, vascular dementia, and other dementing illnesses has increased dramatically in both community and nursing home settings. For example, it is estimated that there were 4.5 million people with Alzheimer's disease in 2000, and by 2050 it is projected to affect 13.2 million people (Hebert, Scherr, Bienas, Bennett, & Evans, 2003). The challenge of providing appropriate, effective care for this growing segment of disabled, terminally ill individuals will increasingly fall to nursing homes because, as one recent study confirmed, the majority (66 percent) of dementia-related deaths occur in this setting (Mitchell, Teno, Miller, & Mor, 2005). In response to this challenge, this article reports on a study in two nursing homes in which advanced illness care teams (AICTs) were developed to improve the comfort, care, and well-being of residents with advanced dementia and to reduce their pain, agitation, and depression.

Improving the comfort, care, and well-being of nursing home residents with dementia is a national health care goal that has been promulgated through federal law and through the recommendations of professional associations. The Nursing Home Reform Act of 1987 mandated that nursing home residents have the right to an environment that promotes quality of life, including physical, mental, and psychosocial well-being, and freedom from chemical and physical restraints for the purpose of behavior management (Beck et al., 2002; Omnibus Budget Reconciliation Act, 1987). The American Geriatrics Society and the American Association for Geriatric Psychiatry have also made recommendations to improve the mental health care that nursing home residents receive (Snowden, Sato, & Roy-Byrne, 2003). These requirements and recommendations for improving nursing home care were intended, in large part, to benefit the growing number of individuals with dementia who make up the majority (50 percent to 80 percent) of the nursing home population (Magaziner et al., 2000; Payne et al., 2002).

In this population of nursing home residents with a dementing illness, improving care often involves treating pain, agitation, and depression; this takes an interdisciplinary approach often involving physicians, nurses, nursing assistants, social workers, allied health professionals such as dieticians, and occupational and physical therapists. It is estimated that 45 percent to 83 percent of nursing home residents regularly suffer with pain (Chu, Schnelle, Cadogan, & Simmons, 2004), and the problem of inadequate pain treatment for nursing home residents with dementia has been a recurrent theme in the literature (Cohen-Mansfield & Lipson, 2002; Nygaard & Jarland, 2005; Won et al., 1999). In addition to the humane concerns this issue raises, inadequately treated pain has been associated with depression (Cipher & Clifford, 2004 Parmalee, Katz, & Lawton, 1991), agitation (Buffum, Miaskowski, Sands, & Brod, 2001; Manfredi et al., 2003), and a reduced level of activity and socialization (Chibnall, Tait, Harman, & Luebbert, 2005).

There have been numerous studies on treating nursing home residents with dementia, depression, and agitation, along with other behavioral symptoms. Snowden and his colleagues (2003) reviewed more than 90 studies in which pharmacological and nonpharmacological approaches were used to treat depression or behavioral symptoms (primarily agitation) in nursing home residents with dementia. The pharmacological trials included antidepressants, antipsychotics, anticonvulsants, and other medications such as melatonin and estrogen. The nonpharmacological approaches covered activity and behavior therapies, staff training interventions, and sensory therapies. However, none of the intervention studies in this review evaluated the use of interdisciplinary teams in the treatment of nursing home residents with dementia. A comprehensive review of the literature for this study confirmed that there have been few studies on the use of specialized or interdisciplinary teams in the treatment of depression, agitation, or other behavioral symptoms in nursing home residents with dementia.

Although clinical health care teams in nursing homes have not attracted a lot of attention, we were able to identify three studies over the past 10 years that described how interdisciplinary teams can improve the care provided to nursing home residents with dementia. One study with a randomized design used weekly team meetings between nursing staff and a psychiatrist, regular medication reviews, and group social activities to improve care (Rovner, Steele, Shmuely, & Folstein, 1996). The study team found that the treatment group experienced significant reductions in problem behaviors and significant reductions in antipsychotic medications and mechanical restraints. In a second study, a team of Swedish researchers using a randomized control trial involving 33 nursing homes found that a multidisciplinary team...

NOTE: All illustrations and photos have been removed from this article.



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