Life In The Slower Lane

Here is the structured PICO analysis for the sixty-second article you uploaded:

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Full Title (verbatim and exact):

“Care-Delivery Interventions to Manage Agitation and Aggression in Dementia Nursing Home and Assisted Living Residents: A Systematic Review and Meta-analysis”

Jutkowitz E, Brasure M, Fuchs E, et al.

Journal of the American Geriatrics Society (2016); 64:477–488

DOI: 10.1111/jgs.13936

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Type of Article:

Systematic review and meta-analysis of randomised controlled trials

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PICO Analysis:

Population:

• Residents with dementia in nursing homes and assisted living facilities
• 19 eligible RCTs included, with 3,566 participants
• Most participants were older adults with moderate to severe dementia 

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Intervention:

Nonpharmacological care-delivery interventions targeting staff and facility practices, including:

1. Dementia care mapping (DCM) (n = 3)
2. Person-centred care (PCC) (n = 3)
3. Clinical protocols to reduce antipsychotic use (n = 3)
4. Emotion-oriented care (n = 2)
5. Eleven unique interventions (e.g., activity programs, team-based care, staff training) 

Each involved structured staff training and/or environmental or care model changes.

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Comparator:

• Usual care in all studies, which typically involved continuation of existing practices, but was poorly described in most cases
• In some cases, a placebo training session or basic dementia education was used as attention control 

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Outcome:

1. Person-centred outcomes:

• Primary outcome: Agitation and aggression (Cohen-Mansfield Agitation Inventory, NPI, BARS, etc.)
  • No pooled intervention group demonstrated clinically meaningful reductions in agitation or aggression
  • Pooled results:
    • DCM: SMD = –0.12 (95% CI: –0.66 to 0.42)
    • PCC: SMD = –0.15 (95% CI: –0.67 to 0.38)
    • Clinical protocols: Mean diff. = –4.5 (95% CI: –38.84 to 29.93)
• Studies often lacked a rationale for how outcomes aligned with treatment goals

2. Process outcomes:

• Staff training was a consistent component but:
  • Training duration, intensity, and fidelity were inconsistently reported
  • No study demonstrated sustained staff behaviour change
• Few studies measured implementation success or staff adherence 

3. Health system outcomes:

• Antipsychotic and psychotropic use:
  • Most studies reported no significant reduction in medication use, including those focused on deprescribing protocols
• Adverse events (falls, hospitalisation, injury): rarely reported and mostly not significantly different between groups
• No studies assessed hospital admissions, ED visits, or cost-effectiveness

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Summary Conclusion:

This high-quality systematic review found insufficient evidence that nonpharmacological care-delivery interventions—such as DCM, PCC, emotion-oriented care, or deprescribing protocols—reduce agitation or aggression in dementia patients living in aged care facilities. While some individual trials showed modest effects, these were rarely clinically meaningful, and most studies had methodological flaws or were underpowered. The review highlights the need for:

• Consistent terminology and validated measures distinguishing agitation from aggression
• Theory-informed interventions with strong implementation support
• Better documentation of training fidelity, staff engagement, and usual care context

Despite the inconclusive findings, the authors argue that efforts to reduce antipsychotic use should continue, given the risks of pharmacological treatment and the absence of harm from psychosocial interventions.

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