Person-centred care and care mapping in dementia.

The Caring for Aged Dementia Care Resident Study (CADRES), published in this issue of The Lancet Neurology, is a cluster-randomised clinical trial in which 324 people with dementia in residential care were randomly assigned one of three treatments: person-centred care, dementiacare mapping, or usual care. Person-centred care puts the person with dementia at the centre of the care-planning process and the care they receive, respecting their wishes and needs as an individual. Dementia-care mapping is a specifi c assessment tool and philosophy designed to improve person-centred care. Both interventions improved agitation compared with usual care at the end of the 4-month treatment phase and over a further 4-month follow-up, and dementia-care mapping was associated with fewer falls. Previous work has shown that person-centred care interventions can reduce the use of antipsychotic drugs in people with dementia, but the current study also shows a signifi cant improvement in agitation. Dementia-care mapping is widely used to develop practice and has been used as a measure of quality of life in research, and open studies have also indicated the value of dementia-care mapping as part of an audit cycle. The newest and most important feature of CADRES is the investigation of dementia-care mapping, with assessment and feedback, as a specifi c intervention in a randomised controlled trial. The improvements in agitation are extremely encouraging and emphasise the importance of further trials with dementia-care mapping. Various care-home interventions, including staff training, exercise, positive-activities, and person-centred care have had signifi cant eff ects on important outcomes such as agitation, depression, drug prescription, and unmet needs, but the benefi ts have been diffi cult to sustain beyond the duration of the intervention, and routine implementation of any of these interventions in routine clinical practice or social care is diffi cult. Dementia-care mapping is particularly appealing as an intervention approach, because it is already widely implemented in clinical practice. Furthermore, the sustaining of benefi ts beyond the intervention period is encouraging. CADRES is an extremely important trial that might greatly aff ect clinical practice. However, important caveats must be taken into account. First, the comparison of the intervention with usual care is problematic because there are probably non-specifi c benefi ts from any intervention. An education-alone intervention might have been a preferable comparator, because it would probably have minimum eff ect but control for non-specifi c benefi ts. Second, the duration of intervention was brief, and longer treatment and follow-up are needed to determine the value of ongoing interventions in clinical practice. Third, the lack of benefi t for psychiatric and behavioural symptoms other than agitation and the absence of any reduction in use of antipsychotics or other psychotropic drugs were disappointing. Furthermore, as in most other trials in dementia care, direct improvement in quality of life of care-home residents was rare. Relative to that in CADRES, treatment was longer and more intensive in the Focused Intervention Training and Support (FITS) trial of person-centred care, which showed substantial reduction in antipsychotic use. Therefore, intensive person-centred care might be needed to change prescription practice. Non-pharmacological interventions, such as exercise and pleasant events, infl uence other neuropsychiatric symptoms, such as depression; a combination of elements from diff erent approaches might be needed to obtain the greatest benefi ts to residents of care homes. Published Online March 12, 2009 DOI:10.1016/S14744422(09)70046-8