Combining micro‐skills to manage dementia agitation: insights from family caregivers

Non-pharmacological approaches are recommended as first-line interventions for the management and treatment of behavioural and psychological symptoms of dementia (BPSD). Micro-skills (MSs), as a non-pharmacological approach, are defined as the communication and interaction skills employed by caregivers for the care of people with dementia.1 MSs are crucial for quality care in responding to and preventing BPSD.1 Previous studies have assessed the effectiveness of different MSs, including emotional support, meeting needs, removing triggers, and distraction.2 However, combinations of different MSs are commonly used.3 We evaluated the combinations of MSs used for responding to agitation, a frequently reported BPSD. A web-based survey was administered to 144 family members caring for people with dementia and agitation in Japan to collect basic information on family members (including their age, sex, and relationship with the person with dementia) and persons with dementia (including their age, sex, level of support and nursing care, type of dementia, and severity of agitation). Additionally, referring to previously published MS categories,2 we asked whether they had ‘0: never had success with the management strategy’ or ‘1: had success with the management strategy’ for each of the following four MSs: (i) ‘consoling and speaking slowly and politely to reassure and calm them (emotional support)’; (ii) ‘meeting his or her needs and wants (meeting the needs)’; (iii) ‘removing the trigger or cause of the agitation (removing direct triggers)’; and (iv) ‘diverting the person's mind and encouraging to join activities (distraction)’. Hierarchical cluster analysis (Ward's method, Euclidean distance) of these responses was conducted to classify combination patterns. Moreover, the data were analyzed to determine the association between the clusters and other variables using Fisher's exact test. EZR software4 and js-STAR_XR+ were used for statistical analyses. Ethics approval was obtained from the Ethics Committee of Higashiosaka Junior College (R2-05). All participants provided informed consent prior to participation. The average age of the family caregivers was 53.0 (±11.7) years; 34.7% of caregivers were female individuals, while 13.1% were the spouses. The average age of the participants with dementia was 84.6 (±9.74) years, with 63.4% being female individuals. Among those with dementia, 50.7% had Alzheimer's disease, while the remaining 49.3% had other dementia types, such as dementia with Lewy bodies, vascular dementia, and frontotemporal dementia. Based on the dendrogram created by cluster analysis, the following five clusters were extracted (Table 1): ‘group using all MSs’; ‘group using skills like meeting the needs, emotional support, and removing direct triggers’; ‘group using skills like distraction, emotional support, and removing direct triggers’; ‘group using skills like emotional support, meeting the needs, and distraction’; and ‘no effective intervention group’. Cluster 1 (the group that used all MSs) had a higher rate of success in managing agitation with each MS (n = 74). This cluster could ‘successfully combine some MSs among the four’ or ‘successfully use a different MS depending on the situation’. Cluster 2 (the group that used skills such as meeting needs, emotional support, and removing direct triggers) noted a lower rate of success with using distractions and higher rate of success with other MSs (n = 30). Although distraction was used as the primary intervention in a previous study,3 diverting attention by inviting an agitated person for walks and refreshments was not found to achieve a fundamental solution.2 Cluster 3 (the group that used skills like distraction, emotional support, and removing direct triggers) noted a lower rate of success with meeting a person's needs and higher rate of success with other MSs (n = 14). Cluster 4 (the group that used skills like emotional support, meeting needs, and distraction) noted a lower rate of success with removing direct triggers and higher rate of success with other MSs (n = 11). Identifying and addressing the needs and agitation triggers in people with dementia are crucial for identifying fundamental solutions. However, adopting this systematic approach is sometimes difficult for family caregivers.5 Cluster 5 (the ‘no effective intervention’ group) noted a low rate of success in managing agitation with each MS (n = 15). Significant differences were found in agitation severity, as presented in the lower part of Table 1. Moreover, the residual analysis showed that, relative to the total, cluster 5 had fewer people with mild agitation and more people with severe agitation (P < 0.05). Prompting and all types of verbal behaviours by caregivers (statements, instructions, and distraction) were at risk of eliciting further resistive behaviour, particularly when the people with dementia were already exhibiting resistiveness to care.6 When resistance was observed and the response was unsatisfactory, some caregivers left the person with dementia alone for a short period of time before returning later.7 When agitation was severe, caregivers might be able to avoid further resistance by evading aggressive intervention. Thus, the adopted method involved allowing the person with dementia to calm down without any active intervention. Emotional support was included in all except cluster 5 and deemed important for managing agitation. However, none of the clusters used emotional support alone. Therefore, a combination of emotional support and other MSs might be the most effective strategy. A previous study4 suggested that MSs are often combined. Providing emotional support initially and then using other MSs to prolong the duration of calmness in patients with dementia could be beneficial in treating agitation. One must note that our data are self-reported, which could have introduced bias, and that the long-term effectiveness of these skills remains unknown. Therefore, multicentre, blind, randomised controlled trials are required to verify the effectiveness of MS combinations. This work was supported by Japan Society for the Promotion of Science (JSPS) Grants-in-Aid for Scientific Research (KAKENHI) (grant numbers 20K19269 and 24K14162). The authors declare they have no conflicts of interest regarding the research. Ethics approval was obtained from the Ethics Committee of Higashiosaka Junior College (R2-05). All participants provided informed consent prior to inclusion in the study. The dataset generated during the current study is not publicly available but is available from the corresponding author upon reasonable request.