Individualized guidelines for the management of aggression in dementia - Part 1: Key concepts

Background: Clinical guidelines have the potential to assist in the management of aggression in dementia. This study aims to develop a conceptual framework for the construction of individualized guidelines for this group. Methods: A concept map of the topic “How to manage aggression in dementia” was developed by reviewing research papers, clinical guidelines, and gray literature. Titles and abstracts of papers that met search criteria were manually scanned in an iterative process for the extraction of key ideas and terminology commonly used to describe the field. Essential ideas and concepts were recorded on a concept map and hierarchically arranged. The concept map was converted into an interactive PDF document for easy distribution and sharing. Results: Ten key concepts were found to be important when managing aggression in dementia clustered along three major dimensions: Patient, Disorder and Treatment. The dimension Patient was defined by the “Patient's individual characteristics,” the “Personal life story,” and the “Patient's environment.” Disorder was defined by the “Presentation of symptoms” and “Theory of causation.” Treatment was defined by “Goals and expectations,” “Non-pharmacological interventions,” “Pharmacological interventions,” “Ethics and Restraint Use,” and “Emergency treatment.” Concepts relating to clinical guidelines themselves were also included in the interactive map, including “Support from evidence-based medicine,” “Regular updates,” “Disclosures,” and “Usability.” Conclusion: Managing aggression in dementia requires consideration of a wide range of factors relating to the patient, the dementia and behavioral disturbance, and possible treatment options. An interactive and hierarchical concept map provides a framework to develop individualized clinical guidelines

Individualized guidelines for the management of aggression in dementia - Part 2: Appraisal of current guidelines

Background: Individualized guidelines have the potential to offer clinicians assistance in decision-making at the point of consultation to improve health outcomes for patients. This project aims to develop individualized guidelines for the management of aggression in dementia. At an earlier stage, we developed a map of concepts to consider when managing aggression. The purpose of the current study is to appraise paper-based guidelines for their representation of these concepts. Methods: Two reviewers used a four-point scale (absent, weak, moderate, strong) to rate the guidelines on their representation of concepts relating to the patient, the aggression and dementia disorder, the treatment, and the guidelines themselves. Consensus was reached on inconsistent scores. Results: Sixteen guidelines published since 2005 were evaluated for their representation of 13 key concepts. Pharmacological and non-pharmacological interventions were strongly represented overall in the guidelines, in conjunction with a consideration of the individual characteristics of the patients and their environment. Recommendations based on the presentation of the aggressive symptoms, goals of treatment, and theory of the cause of the aggression were moderately represented in the guidelines. Recommendations for the principles of restraint use and emergency treatment, as well as a consideration of the personal history of the patient, were poorly represented. Only 6 of 16 guidelines gave details of the expected review. Conclusion: Concepts important to the management of aggression in dementia are missing in the majority of published guidelines on dementia. This limits the ability of these tools to guide clinical practice effectively