Changing Talk Online (CHATO): A Pragmatic Trial to Reduce Behavioral Symptoms in Dementia Care

Background on Condition, Disease, or Other Primary Study Focus: The population afflicted with Alzheimer's disease and other dementias will expand from 5 to 16 million by 2050, increasing dementia care costs from $259 billion to $1.1 trillion. Of today's 1.4 million nursing home (NH) residents, 61% have moderate to severe dementia, and up to 90% of them exhibit behavioral and psychological symptoms of dementia (BPSD) such as physical and verbal aggression, agitation, and wandering. These behaviors are associated with depression as well as reduced quality of life and lower survival rates in persons with dementia (PWD). BPSD also stress family caregivers and precipitate NH placement. In the NH, BPSD increase time to provide care, and NH staff, primarily Certified Nursing Assistants (CNAs) who provide most direct care, report that BPSD represent the most stressful aspect of their job. Considering additional costs for CNA burnout and turnover, It is estimated that BPSD increase costs of dementia care by 25 to 35%. With national NH rates for a semi-private room of $82,200 per year, reducing BPSD may save up to $20,000 per resident annually.

As cognitive and communication abilities decline due to dementia, NH residents become unable to convey care preferences and needs and staff communication becomes infantilizing, impersonal, and task-oriented resulting in BPSD. As verified in the investigator's past research using behavioral coding and sequential analyses of video-recorded care, staff elderspeak (communication that sounds like baby talk) is linked to resident resistiveness to care (RTC), a subset of BPSD that disrupt nursing care. NH residents were more than twice as likely to be resistive to care when staff used elderspeak compared to normal communication. Thus, improving communication has great potential as a nonpharmacological intervention to reduce BPSD in NH care.

Study Rationale: The Communication Predicament of Aging theory establishes the link between elderspeak and BPSD. Elderspeak derives from stereotypical views of older adults as less competent than younger persons. When younger people talk with older adults, they modify their speech by simplifying, clarifying, and altering the underlying affective quality of messages. The resulting implicit message of incompetence begins a negative feedback loop for older persons, who react with depression, withdrawal, and dependency. Elderspeak is especially threatening to self-concept and personhood, critical to the wellbeing of PWD who are likely to respond with BPSD. The Need-driven Dementia-compromised Behavior model recognizes BPSD as the expression of unmet needs of PWD. Communication, that staff can modify to prevent BPSD, is an essential constant part of the environment connecting PWD to others and affirming their self-concept.

Psychotropic medications are often used inappropriately to control BPSD in NH residents with dementia. Alarmingly high rates persist, despite negative outcomes, an FDA black box warning of increased mortality for older adults with dementia, and a recent Centers for Medicare and Medicaid Services (CMS) mandate to reduce off-label prescribing of antipsychotics. CMS and the National Partnership to Improve Dementia Care target reductions in psychotropic drug use as top priority. Despite reductions in antipsychotic rates (one type of psychotropic medication) ranging from 3 to 12% from 2011-2016, up to 20% of NH residents received inappropriate antipsychotic medication in 2017. Research demonstrates that educating direct care providers in behavioral interventions to control BPSD also reduces psychotropic drug use (antipsychotics, hypnotics, antidepressants, antianxiety, sedative, anticonvulsant and mood stabilizers), although evidence is limited by lack of rigorous clinical trials that also evaluate approaches that influence intervention effects.

The recently completed R01 clinical trial that tested Changing Talk (CHAT) communication training (NR011455) provides preliminary data for this CHATO pilot. CHAT decreased staff elderspeak that reduced resident RTC and increased staff awareness of elderspeak's negative effects. CHAT NHs also saw a significant reduction in psychotropic medication use after the training versus averaged state rates. Despite the success of CHAT in reducing elderspeak and RTC, investigators found challenges to educating NH staff that limited participation in CHAT including turnover, absenteeism, heavy workloads, and personal conflicts. Each CHAT session was held multiple days and times. Still, as few as 44% of staff in one NH completed at least two of the three sessions, although this rate is higher than that noted for other NH staff training programs. Although successful in reducing RTC, the classroom format limits staff access and participation and feasibility for widespread dissemination. Creative, efficient approaches are needed to overcome NH staff education barriers. An online web conference training with multiple NHs as an alternative format was first evaluated for increasing access and dissemination. However, engagement of individual staff was limited with this approach. To facilitate dissemination, online CHAT modules (CHATO) were developed to provide the same CHAT content with asynchronous and independent access for busy NH staff.