Journal of Depression and Anxiety
Open Access

WANT Model: The Need-Centered Care and Management Model for Behavioural and Psychological Symptoms of Dementia

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Abstract

Aim: A discussion of a newly developed need-centered care and management model for Behavioural and Psychological Symptoms of Dementia (BPSD) and its practice protocol.

Background: A simple and memorable care and management model for BPSD is needed to guide care-providers especially those working in long-term care facilities.

Design: The model named “WANT” model is the abbreviation of Watch-Assess-Need intervention-Think. Watch- to pay attention to the frequency and status of behaviours of resident with dementia; Assess-to assess relevant background and proximal factors for such behaviours and deduce the needs behind; Need intervention-to implement care measures according to residents’ needs; Think- to reflect on and share mutual experiences with peers. The expert validity of final version of the WANT model reached.

Data sources: The development of the WANT model was through three phases: Literature review, content formulation and expert panel evaluation.

Implications for nursing: Care-providers may integrate the model with daily care process. An education and training protocol based on the WANT model can be widely applied to staff working in long-term care facilities worldwide.

Conclusion: This model can be easily remembered by care-providers and trigger care-providers’ reflection on the causes behind the problems behaviours.

Introduction

The Alzheimer's Disease International (ADI, 2021) reported that over 50 million people worldwide are living with dementia in 2020 and this number will be double every 20 years, reaching 82 million in 2030 and 152 million in 2050. Dementia is a group of symptoms that are not only cognitive dysfunctions but also non-cognitive dysfunctions. The latter are also collectively referred to as Behavioral and Psychological Symptoms of Dementia (BPSD). Approximately 75% of people living with dementia are complicated with BPSD that may take place at any time over the course of dementia and their severity varies with the progression of dementia. Behavioral and psychological symptoms of dementia are usually the main cause leading to family caregivers’ care burden and early transfer of patients to facilities [1]. Common clinical BPSDs include wandering, delusions and hallucinations, depression, pacing and repetitive motor activity, anxiety, screaming, agitation and/or restlessness, repetitive vocalization, cursing and swearing, sleep disturbance, sundown symptoms, aggression and hoarding, etc. Although some medications can be adjusted for target symptoms (e.g. agitation and aggression), the side effects of medications are significant. Many scholars internationally have suggested that non-pharmacological treatment should be prioritized for treating BPSD and drug treatment should be used as an adjuvant treatment when the symptoms cannot be effectively improved [2].

In 2005, Kovach, Noonan, Schlidt, and Wells indicated that the BPSD of people living with dementia are associated with the failure to meet their needs. If care-providers cannot understand the meanings behind these BPSDs, there will be communication barriers, the care provided by them cannot meet patients’ needs, patients’ BPSD will gradually aggravate, and care-providers will also experience higher stress. Treating dementia complicated with BPSD will help reduce the severity of BPSD of people living with dementia and reduce constraint imposed on patients, medication use, and repeated admission, which will further improve patients care quality and decrease the medical costs. The systematic literature review by Reis, Dalpai and Camozzato (2013) summarized the features of dementia care and management models include: Abilities-focused care, Personcentered approach, Behavioral oriented approach with person environment fit, Emotion-oriented approach, Communication Skills, Practice-based approach, and Skills to reduce the need for restraint approach [3].

However, in terms of these models, some of them lack an easy to follow education manual, and others are more complicated and difficult to remember or lack detailed descriptions about educational content. Moreover, people living with dementia complicated with BPSD are individualized and diversified. Therefore, in the current busy care work, it is necessary to develop a simple and memorable management model that assists caregivers in clinical application. In particular, such a model can also rapidly integrate with caregivers’ strategies for daily care process. We proposed a need-driven BPSD care and management model-WANT (Watch-Assess-Need intervention- Think) that can be easily implemented and integrated with daily care at various types of care facilities to effectively manage BPSD of people living with dementia. Hopefully, care-providers’ work efficiency can be improved and the objective of patient-centered high-quality care can also be achieved [4].

Literature Review

Theoretical foundation of the model

This study developed WANT model based on the framework of Need-Driven dementia-compromised Behavior (NDB) model developed by Algase 1996. This model indicates that all the disruptive behaviors of people living with dementia are caused by the failure to meet one or multiple needs, including physiological, mental, emotional, and social needs. Because such patients have lost the ability to express themselves, their BPSD are actually an attempt to communicate with people. The NDB model emphasizes that the cause inducing stress and discomforts in such patients is the fluctuation between personal traits and environment. Dementia-compromised behaviors are affected by background factors and proximal factors. The background factors include: (1) Neurological function factors- brain damage of special parts, imbalanced neurotransmission, physiological clock imbalance, etc; (2) cognitive function factors- attention, memory, visual space ability, language ability, etc; (3) health status- overall health, physical functions, and emotional status; (4) psychosocial factors- gender, education, occupation, personality, medical history of mental stress, and behavioral responses to stress. The proximal factors include (1) personal factors- emotions, physiological need status, and executive ability; (2) physical environment-light, noise, and temperature; (3) social environment-ward atmosphere, stability of staff, composition of staff, etc. Kovach et al. also described that the BPSD of people living with dementia are a symbol of unmet needs. These symptoms are not caused by a single factor, but the syndrome caused by multiple factors [5].

In addition, our study team had investigated a series of common BPSD-related background and proximal factors in people living with dementia, and the needs behind theme based on the NDB model. We further found that the reappearance of inner personality and habits, the resurgence of past economic crisis, lack of security, changes in living conditions, monotonous life, the search for inner comfort, prohibited old habits and customs, ignored emotions or alienation, physical discomfort, desire to maintain self-control, emotional venting, attention seeking, the desire for safety, the need for a sense of belonging, the need to connect with the outside world, and self-control are the causes inducing BPSD in patients or aggravating the severity of BPSD. All the empirical data mentioned above have become the fundamental data for developing the need-driven WANT care and management model for people living with dementia [6].

The WANT model

The WANT care and management model for people living with dementia is a “need-centered” care model, suggesting that residents’ needs can be observed from their behavioural characteristics and intervention measures can be implemented to meet their needs. When care-providers discover BPSD in resident with dementia, they usually think about: “What does he/she want?” The English term “WANT” means “need” or “requirement.” Therefore, WANT is the abbreviation of Watch- Assess-Need intervention-Think. Watch-to pay attention to the frequency and status of BPSD of people living with dementia; Assess to assess relevant background factors and proximal factor for such behaviors and deduce the needs behind; Need intervention- to implement care measures according to patients’ needs; Think- to reflect on and share mutual experiences with peers. The abbreviation and meaning of this model both mean “WANT.” The development of WANT model was divided into 3 phases.

Phase-1 systematic reviews: Firstly, we searched for the Keywords (dementia, dementia BPSD, dementia management model, dementia care, causes and needs of BPSD, etc.) in databases CINAHL, MEDLINE, Pro Quest nursing, PubMed, CEPT, GOOGLE SCHOLAR to find out the causes and needs behind BPSD of dementia complicated with BPSD in domestic and foreign literature, individualized BPSD care approaches, and management model for dementia complicated with BPSD. After multiple discussions and modifications, the study team preliminarily summarized various common causes, needs, and care strategies or approaches behind the BPSD in the WANT model as the preliminary resources for the development of meanings of the model [7-9].

Phase-2 development of WANT model content: We developed the learning manual for multiple common and troublesome BPSD scenarios, including factors associated with common behaviors, such as wandering, aggression, change in dietary habit, delusions, and sundown symptoms, needs behind, and care treatments and strategies. The corresponding cases and scenarios according to the sequential order and steps of WANT model were developed, and then simple and comprehensible content were constantly discussed about and reflected on the content to develop the model, which was then tested using expert content validity.

Phase-3 expert panel: This study invited 5 experts to convene the expert panel (including experts in academic nursing, institutional nursing supervisors, institutional senior nurses, etc.). Firstly, this study sent written documents to the experts, and then invited them to review such documents without scoring them. Afterwards, an expert panel was scheduled for all the experts. The researcher hosted the expert panel where the experts were invited to score the appropriateness of finalized dementia BPSD management model (4 points: Appropriate, no modifications needed; 3 points: Appropriate, only partial modifications are required; 2 point: Appropriate, but need greatly modification; 1 point: Inappropriate/recommended to be deleted). After the expert panel, the model was modified according to experts’ comments. Moreover, this study continued communicating with the experts via email until the Content Validity Index (CVI) reaches and the expert validity of final version of the WANT model reached [10,11].

Discussion and Conclusion

In the society of increasingly severe trend of aging, attention should be paid to dementia care issues. People living with dementia should be understood, instead of being ignored. People living with dementia may be unable to express their needs, which should not be overlooked to prevent people living with dementia from falling into a painful situation. If the firstline care-providers are able to discover the BPSDs of people living with dementia and pay more attention to the analysis of their BPSDs, they can effectively help meet residents’ needs, which will help improve the care quality and enable people living with dementia live with a sense of safety and dignity. The current international trends of dementia care are to take care of elderly people living with dementia in a more humanized manner and to develop person-centered individualized care measures. Therefore, this WANT care and management model will help alleviate the BPSD of people living with dementia, reduce their restraints, medication, and repeated admission rate to further improve caregiver relationship and care quality and reduce the medical costs of dementia complicated with BPSD.

References

1. Algase DL, Beck C, Kolanowski A, Whall A, Berent S, Richards K, et al. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. Am J Alzheimer's Dis. 1996;11(6):10-19.

   [Cross ref] [Google Scholar] [Pub Med]

2. Hsiao HC, Chao HC, Wang JJ. Features of problematic eating behaviors among community-dwelling older adults with dementia: Family caregivers' experience. Geriatr Nurs. 2013;34(5):361-365.

   [Cross ref] [Google Scholar] [Pub Med]

3. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350.

   [Cross ref] [Pub Med] [Google Scholar]

4. Kovach CR, Noonan PE, Schlidt AM, Wells T. A model of consequences of need�driven, dementia�compromised behavior. J Nurs Scholar. 2005;37(2):134-140.

   [Cross ref] [Google Scholar] [PubMed]

5. Reis RC, Dalpai D, Camozzato A. Staff training to reduce behavioral and psychiatric symptoms of dementia in nursing home residents: A systematic review of intervention reproducibility. Dement Neuropsychol. 2013;7:292-297.

   [Cross ref] [Google Scholar]

6. Sampson EL, White N, Leurent B, Scott S, Lord K, Round J, et al. Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: Prospective cohort study. Br J Psychiatr. 2014;205(3):189-196.

   [Cross ref] [Google Scholar] [Pub Med]

7. Shih YH, Pai MC, Huang YC, Wang JJ. Sundown syndrome, sleep quality, and walking among community-dwelling people with Alzheimer disease. J Am Med Director Assoc. 2017;18(5):396-401.

   [Cross ref] [Google Scholar] [Pub Med]

8. Wang CJ, Pai MC, Hsiao HS, Wang JJ. The investigation and comparison of the underlying needs of common disruptive behaviours in patients with Alzheimer's disease. Scand J Caring Sci. 2015;29(4):769-775.

   [Cross ref] [Google Scholar]

9. Wang JJ, Cheng WY, Lai PR, Pai MC. Delusions and underlying needs in older adults with Alzheimer’s disease: Influence of earlier life experiences and the current environment. J Gerontol Nurs. 2014;40(12):38-47.

   [Cross ref] [Google Scholar] [Pub Med]

10. Wang JJ, Feldt K, Cheng WY. Characteristics and underlying meaning of hoarding behavior in elders with Alzheimer’s dementia: Caregivers’ perspective. J Nurs Res. 2012;20(3):189-196.

    [Google Scholar] [PubMed]

11. Wood-Mitchell A, James IA, Waterworth A, Swann A, Ballard C. Factors influencing the prescribing of medications by old age psychiatrists for behavioural and psychological symptoms of dementia: A qualitative study. Age Ageing. 2008;37(5):547-552.

    [Cross ref] [Google Scholar] [Pub Med]