Framework and Evidence to Develop Care Practices

Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
Using a PICO(T) Framework and Evidence to Develop Care Practices
Learners Name
Capella University
Making Evidence-Based Decisions
PICO(T) Questions and an Evidence-Based Approach
January, 2019
Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
Using a PICO(T) Framework and Evidence to Develop Care Practices
When developing care practices for patients, the PICO(T) research framework, which
expands to Population/Patient, Intervention, Comparison, Outcome, and Time, can be used to
create an effective care plan and ensure that patients needs are met. Relying on secondary
research, the author of this paper will define a practice issue surrounding patients with dementia,
apply the PICO(T) process, identify sources of evidence that may provide answers to the
research question, explain key findings from articles, and explain the relevance of those key
Use of the PICO(T) Approach when Caring for Patients with Dementia
The practice issue identified for resolution is the need to develop care practices that
effectively manage agitation in patients with dementia in nursing homes that are outside of
pharmacological approaches. The question being explored is: Is the non-pharmacological
approach, specifically an intervention approach, more effective than the pharmacological
approach in managing behavioral symptoms (such as agitation) in patients with dementia?
The intervention approach identified is person-centered care or patient-centered care
(PCC), an approach that emphasizes more on an individuals experiences and the communication
of his or her needs than on the pure implementation of a health care providers expertise (Desai,
Wharton, Struble, & Blazek, 2017). The population being studied are patients with dementia
with agitative behavioral symptoms in nursing homes. As the objective is to explore care
practices that address this issue, only factors related to care in nursing homes are considered. The
study does not take into consideration cultural, political, and social factors (Kim & Park, 2017).
Identification of Sources of Evidence
DICE Model
Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
The DICE (Describe, Investigate, Create, and Evaluate) model is a notable PCC
intervention model that identifies optimal treatment options for patients with dementia with
neuropsychiatric symptoms. Developed by a panel of interdisciplinary experts at the University
of Michigan Program for Positive Aging, the model is constitutive of a four-step approach. The
first step of the approach is the accurate description of the patients behavior, the second is the
identification of possible underlying causes, the third is the creation and implementation of
treatment plans, and the fourth is the assessment of the strategies developed (Desai et al., 2017;
Kales, Gitlin, & Lyketsos, 2014).
The models essential recommendations for facilitating improvement in neuropsychiatric
symptoms among patients with dementia are educating the caregiver; forging better
communication between the patient and the caregiver; assisting the caregiver in organizing
meaningful activities such as cooking, painting, or reading depending on the patients interests;
and training the caregiver on simplifying his or her work routines (Desai et al., 2017; Kales,
Gitlin, & Lyketsos, 2014).
Individualized Intervention Model
The individualized intervention model is a model in which intervention activities are carried
out based on the history, needs, abilities, and preferences of patients with dementia. In this
model, PCC-based activities are directly carried out by trained health care staff with expertise in
social work, recreational therapy, geriatric psychiatry, and psychology (Kim & Park, 2017).

In the care staffdirected model, PCC activities are based on the staffs education and
training on empathy and person-centeredness. The model also makes a provision for offering
Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
staff regular feedback for their work. The intervention period in such a model ranges from 3
months to 2 years (Kim & Park, 2017).
Findings from Articles
As PCC is a major nonpharmacological approach to treating agitation in patients with
dementia, its effectiveness is studied by making a comparative analysis to the pharmacological
approach to manage behavioral symptoms in patients with dementia. Pharmacological treatment
in general refers to the use of psychotropic medication to manage agitation or neuropsychotic
symptoms (NPS) in patients with dementia (Madhusoodanan & Ting, 2014; Kales et al., 2014).
Some of the common pharmacological interventions include the use of antipsychotropics,
antidepressants such as sertraline and citalopram, and sedative-hypnotics through the use of
benzodiazepines to control acute agitation (Madhusoodanan & Ting, 2014). The use of
psychotropic medication poses high risks of mortality and harmful side effects (Kales et al.,
2014). Psychotropic medication is also expensive and is restricted by regulatory bodies.
However, the use of pharmacological intervention is justified when the benefits outweigh the
risks or in situations wherein nonpharmacological interventions have proven unsuccessful
(Madhusoodanan & Ting, 2014).
The PCC approach has proven effective in addressing the etiology of aggressive
outbursts. Unlike the pharmacological approach, which is based on treating symptoms, the PCC
approach contributes to the resolution of underlying causes (Desai et al., 2017). The study by
Kales et al. (2014) finds reasonable evidence of the DICE programs contribution toward better
clinical practices and improvement in aggressive behavior, and it observes that the approach
results in fewer hospitalizations and readmissions. In their systematic review and meta-analysis
of 19 primary studies, Kim and Park (2017) found 15 studies that measure the impact of PCC on
Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
agitation using the (an agitation mapping instrument) and
the Brief Agitation Rating Scale. They found that 8 of the 15 studies show positive effects on
agitation with individualized interventions (with a significant mean difference of -0.513),
showing better effects than with care staffdirected interventions (with a significant mean
difference of -0.160).
As this paper relies on secondary research on the PCC intervention to manage agitative
behavior in patients with dementia in nursing homes, there are multiple time frames for the
various intervention studies reviewed. While some studies had a long intervention period ranging
from 9 months to 2 years, others had shorter intervention periods of just a few weeks. From the
above exploration of the research problem based on the PICO(T) framework, it is clear that this
framework has contributed to the delineation of precise intervention practices and has brought
conceptual clarity on the issue of agitative behavior in patients with dementia.
Relevance of Findings from Articles
The study by Kales et al. (2014) was chosen as it provides a comprehensive explanation
of the PCC-based DICE intervention program and its potential outcomes and draws an objective
comparison of the program with pharmacological intervention. The study observed that the
DICE model was developed by a panel of experts with years of clinical and research expertise in
managing NPS in patients with dementia. The strategies formulated in the DICE approach were
found to carry a strong evidence base. As it is evidence-informed, the DICE approach could be
helpful for clinicians across diverse settings. Kales et al. (2014) conclude their study with a
discussion on the potential of the DICE approach in enhancing clinical practices and ensuring the
treatment of agitative behavior in patients with dementia.
Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
The rationale for selecting the study by Kim and Park (2017) was that it presents a
systematic review and meta-analysis of 19 primary intervention studies, of which 17 studies are
from long-term care facilities. In their systematic review and meta-analysis of these studies, Kim
and Park (2017) found that PCC has a significant impact on reducing NPS in patients with
dementia. Kim and Parks (2017) review found the increased engagement between care
providers and patients and the magnitude of the programs intensity to be the reasons for shortterm PCC intervention having greater benefits in comparison to long-term intervention. The
findings are relevant because they are based on 17 long-term, clinical PCC intervention studies
comprising both controlled and non-controlled cluster-randomized trials conducted over the past
10 years (Kim & Park, 2017).
Kim & Parks findings prove to be the most credible. In their systematic review and
meta-analysis of primary studies, Kim and Parks findings (2017) adhere to the guidelines of the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses. They also utilize analysis
tools such as the Cochrane Collaborations risk of bias and the risk of bias assessment tool to
ensure quality screening of the studies.
There is a need to develop care practices that are outside of pharmacological approaches
for managing agitation in patients with dementia. The PICO(T) framework was applied to
determine if the intervention approach of person-centered care or patient-centered care (PCC)
was more effective than the pharmacological approach by identifying sources of evidence,
explaining the findings and proving the relevance of those findings. The articles by Kales et al.
(2014) and Kim and Park (2017), provide precise, reliable, and relevant information to
adequately explore the effectiveness of the PCC approach.
Copyright 2019 Capella University. Copy and distribution of this document are prohibited.
Desai, A., Wharton, T., Struble, L., & Blazek, M. (2017). Person-centered primary care
strategies for assessment of and intervention for aggressive behaviors in dementia.
Journal of Gerontological Nursing, 43(2), 917. Retrieved from
Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2014). Management of neuropsychiatric
symptoms of dementia in clinical settings: Recommendations from a multidisciplinary
expert panel. Journal of the American Geriatrics Society, 62(4), 762769. Retrieved from
Kim, S. K. & Park, M. (2017). Effectiveness of person-centered care on people with dementia: A
systematic review and meta-analysis. Clinical Interventions in Aging, 12, 381397.
Retrieved from
Madhusoodanan, S., & Ting, M. B. (2014). Pharmacological management of behavioral
symptoms associated with dementia. World Journal of Psychiatry, 4(4), 7279. Retrieved

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