Effects of an Educational Program for Professional Caregivers on Behavioral Alterations in Nursing Home Residents: Pilot Study
Round 1
Reviewer 1 Report
General comments
The authors of this paper have considered the use of an education program as an alternative to manage the behavioural aspects associated with dementia other than pharmacological management.
Although a lot of clear ideas have been presented within the manuscript, the authors should consider writing some sections more succinctly and use active language throughout. For example, some of the information presented in the introduction could be clearer.
Please so make sure that there is consistency throughout the text in describing the residents. Eg. The authors use a variety of terms ‘older adults’, ‘institutionalized people’ etc…. Also try to use the authors last names when beginning a sentence instead of ‘the study, ’one study, ’one review’ etc… throughout the manuscript.
Double check that all in-text references are cited appropriately. Eg. P 2 L-46.
Specific comments
Title
AT the beginning of the title please change the word ‘a’ to ‘an’
Abstract
P 1-L14 – please write out the number of participants if the authors are going to use this at the start of the sentence. Also please make sure it is clear who is made up of the 145 ‘people’. This seems to be related to the residents living within the aged care facility, not the staff involved in the education training. Should the authors be describing both samples separately here?
P 1-L18 – is this information correct? Was the program carried out in 20 hours? Under the procedures the authors describe collecting data in 6 month intervals over 5 time points. Please make sure this information is clear in the abstract.
P 1-L18 –include some of the statistics in brackets to support your results.
P1-L23 – do not overstate your findings. Eg. The authors state “…it is necessary to train professionals….” Maybe they could rephrase this sentence to something along the lines of...’Educating health professionals on ways to care for residents who present behavioural alterations may be one alternative to improve the quality of care residents received.’
P1 – L 26 – please conclude the abstract with the implications of this study.
Introduction
P 2-L51 – please rephrase this sentence
P2-L57 – make sure to have a clear topic sentence. The use of ‘in this sense’ would be better if it was leading on from an idea presented in the middle of a paragraph not at the start of a new one.
P2-L64 – please provide further description of ‘this BPSD approach.’ This seems to be the jumping off point/justification for the study presented, however what this comprises of has not been clearly described.
P2 – L66 – remove ‘been’
P2 – L68 - remove ‘especially’
P2-L70 - please rephrase this sentence, beginning with ‘one line’ is not clear
P2-L74 - include ‘is’ between ‘sense,’ and ‘it’
P2-L78-88 – please try to rephrase these sections into one paragraph so the need and the aims of the study are clearly justified and supported.
Methods
Participants
Please clearly describe the participants in the study and make sure all of the inclusion/exclusion criteria has been provided. Eg. Where the participants screened for the presence of BPSD prior to their involvement in the study?
P2-L92 – include ‘more’ between ‘leads’ and ‘than’ and maybe include this information in brackets as it distracts from the 2 aged care facilities who actually participated in the study.
P2-L93 – make sure to use brackets as follows: eg. [experimental group (EG), N = 82]
P3-L94 – please rephrase from ‘the centre of the EG’… to ‘The EG centre’…
P3-L95 – please remove ‘is a centre’
P3-L99-116 – these sections could to be reworked significantly as some of the information presented here should be included other sections, eg results. This section should focus on describing the participants. Here it would also be beneficial to include a description of the setting of how aged care facilities look in the country where the study was conducted.
Instruments
Please make sure all instruments are clearly described in this section. In addition, please name and describe which instruments were adopted and in what way. For example, were cross-cultural adaptions completed? Where they tested for validity and reliability?
Please clearly describe the NPI. Eg expand on the format of the questionnaire and include information on the 12 BPSD collected in this instrument. It is also not clear if this is the primary outcome for this study. Also could the authors please justify why they used the NPI and not the NPI-NH? As the study was completed in an aged care setting.
Procedure
This section could also be better organised, please describe the training for the staff members, including the amount of time required. Then clearly describe the duration of the intervention and data collection time points associated. Please also considering presenting this information as a Figure.
P3 L 136 – write this sentence in the past tense.
P4-L 147 – write hours out in full
P4 L 150 – in Table 1 the authors describe three sessions, and then describe three modules – are these referring to different elements of the educational session? If they are referring to the same thing, please make sure the information is consistent.
P4-L 153 –rephrase the end of this sentence from ‘aimed to training’ to …’aimed to the training needs of’…. And describe who the training was tailored for.
P4-L 153 – 168 – could this section be written more succinctly and the order in which the approaches included follow the modules outlined above? Eg Person-Centred Approach is a part of module 1 but described after The communication Approach which is related to module 3.
P4 – L 168 – could the authors include a description of which professionals carried out the education sessions?
Data analysis
This session has been well described.
P4 – 170 change ‘in regard’ to ‘in regards’
Results
Please include descriptive data from the participants here first (mostly presented in the participant section currently). Also the data for the ‘variables evaluated through tests and scales’ (as described under instruments) have not been reported.
P5 – L 180 – present the MMSE results first and then comment separately about the moderate impairment scale.
In Table 2 please make sure all relevant information is presented. Eg the sample for EG and CG have not been included. Under time should this be changed from ‘ting’ to ‘time’? Also please clearly describe what is being presented under EG/CG – are these beta coefficients?
Discussion
Please begin the discussion with a summary of the results and make sure to provide a description of what was found in other studies, avoid just saying that this has been demonstrated in previous studies. Go that extra step and describe what was found. This will make the discussion more interesting and then allow for the authors to provide further links to what they have found and try to explain why they have seen what they have. For example, could the authors focus more on describing other studies that have considered education based approaches and then compare if their findings are similar?
Limitations
Some of the limitations for the study have been presented. Could the authors also comment here if further training was followed up after the completion of the study or if retraining and up skilling was offered? Please try to rewrite this section using more active language. Also cite the STAR project in full first.
Author Response
General comments
The authors of this paper have considered the use of an education program as an alternative to manage the behavioural aspects associated with dementia other than pharmacological management.
Although a lot of clear ideas have been presented within the manuscript, the authors should consider writing some sections more succinctly and use active language throughout. For example, some of the information presented in the introduction could be clearer.
Please so make sure that there is consistency throughout the text in describing the residents. Eg. The authors use a variety of terms ‘older adults’, ‘institutionalized people’ etc…. Also try to use the authors last names when beginning a sentence instead of ‘the study, ’one study, ’one review’ etc… throughout the manuscript.
Double check that all in-text references are cited appropriately. Eg. P 2 L-46.
This aspects has been changed.
Specific comments
Title
AT the beginning of the title please change the word ‘a’ to ‘an’
According to the reviewer has been replaced “a” for “an”
Abstract
P 1-L14 – please write out the number of participants if the authors are going to use this at the start of the sentence. Also please make sure it is clear who is made up of the 145 ‘people’. This seems to be related to the residents living within the aged care facility, not the staff involved in the education training. Should the authors be describing both samples separately here?
According to the reviewer more information regarding professionals sample has been added.
P 1-L18 – is this information correct? Was the program carried out in 20 hours? Under the procedures the authors describe collecting data in 6 month intervals over 5 time points. Please make sure this information is clear in the abstract.
The procedure has been clarified and it’s more clear now.
P 1-L18 –include some of the statistics in brackets to support your results.
Some statistics has been added in abstract
1-L23 – do not overstate your findings. Eg. The authors state “…it is necessary to train professionals….” Maybe they could rephrase this sentence to something along the lines of...’Educating health professionals on ways to care for residents who present behavioural alterations may be one alternative to improve the quality of care residents received.’
According to the reviewer we have change this idea
P1 – L 26 – please conclude the abstract with the implications of this study.
A conclusion with implications of this study has been written
Introduction
P 2-L51 – please rephrase this sentence
The sentence has been rephrase
P2-L57 – make sure to have a clear topic sentence. The use of ‘in this sense’ would be better if it was leading on from an idea presented in the middle of a paragraph not at the start of a new one.
We have remove ‘in this sense’
P2-L64 – please provide further description of ‘this BPSD approach.’ This seems to be the jumping off point/justification for the study presented, however what this comprises of has not been clearly described.
The authors have addressed this issue by specifying information about the NPI
P2 – L66 – remove ‘been’
The authors have removed ‘been’
P2 – L68 - remove ‘especially’
The authors have removed ‘especially’
P2-L70 - please rephrase this sentence, beginning with ‘one line’ is not clear
We have rewrote this paragraph
P2-L74 - include ‘is’ between ‘sense,’ and ‘it’
It has been included
P2-L78-88 – please try to rephrase these sections into one paragraph so the need and the aims of the study are clearly justified and supported.
These sections (pp78-88) has been rephrase into one paragraph.
Methods
Participants
Please clearly describe the participants in the study and make sure all of the inclusion/exclusion criteria has been provided. Eg. Where the participants screened for the presence of BPSD prior to their involvement in the study?
The authors did not consider the presence or absence of BPSD through the NPI scale as criteria for inclusion because some patients score low on the scale because the Psychotropic drugs has regulated their BPSD. Similarly, not only patients diagnosed with dementia were selected, since BPSDs can present as prodromal symptoms of the disease. In a healthy older person this could indicate early dementia or be a risk factor for the future development of dementia (Reyes-Figueroa et al., 2010; Van der Linde, Stephan, Savva, Dening & Brayne, 2012). What has been referred to as Mild Behavoural Impairment (MBI) (Ismail et al., 2016).
The sentences has been included.
Reyes-Figueroa, J. C., Rosich-Estragó, M., Bordas-Buera, E., Gaviria-Gómez, A. M., Vilella-Cuadrada, E. y Labad-Alquézar, A. (2010). Síntomas psicológicos y conductuales como factores de progresión a demencia tipo Alzheimer en el deterioro cognitivo leve. Revista de Neurología, 50 (11), 653-660. DOI: https://0-doi-org.brum.beds.ac.uk/10.33588/rn.5011.2009714.
Van Der Linde, R., Stephan, B., Savva, G., Dening, T. y Brayne, C. (2012). Systematic reviews on behavioural and psychological symptoms in the older or demented population. Alzheimer’s Research & Therapy, 4, 1-23. DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/alzrt131.
Ismail, Z., Smith, E. E., Geda, Y., Sultzer, D., Brodaty, H., Smith, G., Agüera-Ortiz, L., Sweet, R., Miller, D. y Lyketsos, C. G. (2016). Neuropsychiatric symptoms as early manifestations of emergent dementia: provisional diagnostic criteria for mild behavioral impairment. Alzheimer’s & Dementia, 12 (2), 195-202. DOI: https://0-doi-org.brum.beds.ac.uk/10.1016/j. jalz.2015.05.017
P2-L92 – include ‘more’ between ‘leads’ and ‘than’ and maybe include this information in brackets as it distracts from the 2 aged care facilities who actually participated in the study.
It has been included
P2-L93 – make sure to use brackets as follows: eg. [experimental group (EG), N = 82]
We have use brackets
P3-L94 – please rephrase from ‘the centre of the EG’… to ‘The EG centre’…
It has been changed
P3-L95 – please remove ‘is a centre’
It has been removed
P3-L99-116 – these sections could to be reworked significantly as some of the information presented here should be included other sections, eg results. This section should focus on describing the participants. Here it would also be beneficial to include a description of the setting of how aged care facilities look in the country where the study was conducted.
The authors have organized again the information and added a centre description
Instruments
Please make sure all instruments are clearly described in this section. In addition, please name and describe which instruments were adopted and in what way. For example, were cross-cultural adaptions completed? Where they tested for validity and reliability?
The authors have clarified that they used the Spanish version of MMSE
Please clearly describe the NPI. Eg expand on the format of the questionnaire and include information on the 12 BPSD collected in this instrument. It is also not clear if this is the primary outcome for this study. Also could the authors please justify why they used the NPI and not the NPI-NH? As the study was completed in an aged care setting.
The authors have described the NPI and have explained why they have used this tool.
Procedure
This section could also be better organised, please describe the training for the staff members, including the amount of time required. Then clearly describe the duration of the intervention and data collection time points associated. Please also considering presenting this information as a Figure.
P3 L 136 – write this sentence in the past tense.
The sentence has been modified.
P4-L 147 – write hours out in full
The authors have specified the hours they have used for each part of the educational program
P4 L 150 – in Table 1 the authors describe three sessions, and then describe three modules – are these referring to different elements of the educational session? If they are referring to the same thing, please make sure the information is consistent.
The terms have been modified
P4-L 153 –rephrase the end of this sentence from ‘aimed to training’ to …’aimed to the training needs of’…. And describe who the training was tailored for.
The indicated sentence has been rewritten
P4-L 153 – 168 – could this section be written more succinctly and the order in which the approaches included follow the modules outlined above? Eg Person-Centred Approach is a part of module 1 but described after The communication Approach which is related to module 3.
We have summarized and organized the information.
P4 – L 168 – could the authors include a description of which professionals carried out the education sessions?
We have included a description about professionals who carried out the sessions
Data analysis
This session has been well described.
P4 – 170 change ‘in regard’ to ‘in regards’
The authors have replaced the word: “‘in regard’” for “in regards”
Results
Please include descriptive data from the participants here first (mostly presented in the participant section currently). Also the data for the ‘variables evaluated through tests and scales’ (as described under instruments) have not been reported.
The authors have included the descriptive data of the participants at the beginning.
In relation of the variables evaluated through tests and scales, we haven’t reported separately.
On the tables the means obtained in the variables for each period are presented.
P5 – L 180 – present the MMSE results first and then comment separately about the moderate impairment scale.
We have presented MMSE results at the beginning
In Table 2 please make sure all relevant information is presented. Eg the sample for EG and CG have not been included. Under time should this be changed from ‘ting’ to ‘time’? Also please clearly describe what is being presented under EG/CG – are these beta coefficients?
The sample for EG and CG has been described previously in the Results (Section 3.1.) where data are presented.
The sample is the same at all times.
The authors use “ting” to refer to the measurement of the psychotropic drugs at the time of admission (time of admission, “tiempo ingreso” in Spanish), for that reason this only appears in table 3 in reference to psychotropic drugs. “ting" has been eliminated since this measure does not bring results to the study. This data has been eliminated from table 3 because it’s an error of the authors.
The title of the table has been change for explain and clearly describe what is being presented under EG/CG.
Discussion
Please begin the discussion with a summary of the results and make sure to provide a description of what was found in other studies, avoid just saying that this has been demonstrated in previous studies. Go that extra step and describe what was found. This will make the discussion more interesting and then allow for the authors to provide further links to what they have found and try to explain why they have seen what they have. For example, could the authors focus more on describing other studies that have considered education based approaches and then compare if their findings are similar?
The authors agree with the reviewer and have made changes to the discussion.
Limitations
Some of the limitations for the study have been presented. Could the authors also comment here if further training was followed up after the completion of the study or if retraining and up skilling was offered? Please try to rewrite this section using more active language. Also cite the STAR project in full first.
This idea, has been presented in Limitations section. Furthermore, a STAR Project has been added in the Introduction.
Author Response File: 
Author Response.doc
Reviewer 2 Report
Thank you for the kind invitation to review this interesting paper. Intervention to support professional carers of people with dementia are very important. Thus, this is of potential interest to clinicians, support organisations and the nursing home sector. This is particularly apt due to intense pressure being experienced by care homes due to the Covid-19 pandemic.
This is a small trial aiming to evaluate the effectiveness of non-pharmacological intervention involving educational and training of professional caregivers regarding behavioural alterations and prescription of psychotropic drugs of older adults in nursing homes.
The sample size was n=145 people from two nursing homes, one which received the intervention (educational training program for healthcare professionals) and the other did not. A pre and post-treatment and 3 follow-up measures after the intervention were performed, consisting of the behavioural alterations and psychopharmacological treatment.
Concerns for the authors to address:
Since this is a small trial, it should be treated as a pilot or feasibility study, not an effectiveness study for which a proper power analysis and sample size calculation is needed.
Ideally, this type of study should be carried out in multiple care homes using a cluster randomised trial design.
The inclusion criteria for the a) the care workers and b) the participant residents were not clearly laid out. Did they all have dementia? If so, what stage of dementia? What about BPSD? Did they have some level of BPSD at baseline?
The capacity of residents to participate in the study was not discussed. This is a crucial ethical issue that needs a significant level of detail. Were families involved in the decision to participate? If residents had capacity at the beginning of the study, did any lose capacity during the study and how was this managed?
Blinding of raters: No mention is made of blinding of raters to the intervention arm of the study. This is a significant flaw as significant bias will be introduced otherwise.
Consort diagram: The authors need to include a CONSORT diagram to make clear what numbers of residents were eligible, how many were approached, how many consented, how many passed screening etc.
Outcomes: Why was the nursing home version of the NPI not used? This tool is more specific for the setting. Who were the informants for the NPI outcomes? If it was the care home workers who received the training, then the study design is significantly flawed. The informants AND raters need to be blind to the intervention.
What was the primary outcome measure of interest? The authors list both cognitive and behavioural outcomes. Ideally there should be only one primary outcome, and, in a study of this size, it should be feasibility and/or acceptability of the intervention, not effectiveness.
Basis for the intervention: The theoretical basis for the intervention and the background, including field trialing of the intervention need to be discussed in more detail.
Intervention delivery and fidelity: The authors have not included any detail about the adherence of the staff to the teaching of the intervention. Indeed, no information about staff engagement with the intervention is included. Process measures are essential in a study of this type of intervention. This is lacking here.
There was no mention at all about the impact of the COVID-19 pandemic which has hit the care home sector particularly hard. If the study was done pre-COVID, then implications for this type of intervention in COVID or post-COVID era need to be mentioned.
There is minimal description of the nursing home characteristics - were they similar? What was the model of care? What was staff training like? How were differences accounted for? etc.
Minor issues
The authors may want to have their manuscript checked by a native English medical writer. Some of the terminology was non-standard.
Please refer to ‘people with dementia’ rather than ‘patients’; alternatively, they can be referred to as ‘residents’ since the nursing home is where they live.
Please refer to ‘participants’ in the study, not ‘subjects’. This is derogatory.
Please correct the referencing – when using a reference manager [x], author names should not appear, i.e. (Steppacher and Kissler, 2018)
This statement is very outdated ‘BPSD are treated mainly with psychotropic drugs (anxiolytics, antidepressants, 51antipsychotics...)’ few places these days would prioritise psychotropic medications over non-medication interventions (see Guidelines from most societies and national dementia strategies) – the authors should refer to these and cite the literature on this topic; they can then refer to the fact that in spite of these guidelines, bad practice of excess psychotropic use still exists in some care homes (citations needed).
Please do not use ‘…’ (i.e. antipsychotics...)
This statement is not accurate: ‘In this sense, one review [11] highlights the importance of non-pharmacological interventions against pharmacological interventions since they do not entail secondary effects, they imply a lower cost and have been shown to have positive effects’. In fact, there is a huge literature on the topic and the authors need to acknowledge this.
This statement is very outdated as this view is the established one and has been around for many years: ‘A non-pharmacological intervention that is 59gaining more and more momentum is the one that views BPSD as an expression of unmet needs’.
Author Response
Thank you for the kind invitation to review this interesting paper. Intervention to support professional carers of people with dementia are very important. Thus, this is of potential interest to clinicians, support organisations and the nursing home sector. This is particularly apt due to intense pressure being experienced by care homes due to the Covid-19 pandemic.
This is a small trial aiming to evaluate the effectiveness of non-pharmacological intervention involving educational and training of professional caregivers regarding behavioural alterations and prescription of psychotropic drugs of older adults in nursing homes.
The sample size was n=145 people from two nursing homes, one which received the intervention (educational training program for healthcare professionals) and the other did not. A pre and post-treatment and 3 follow-up measures after the intervention were performed, consisting of the behavioural alterations and psychopharmacological treatment.
Concerns for the authors to address:
Since this is a small trial, it should be treated as a pilot or feasibility study, not an effectiveness study for which a proper power analysis and sample size calculation is needed.
The authors have mentioned this aspect.
Ideally, this type of study should be carried out in multiple care homes using a cluster randomised trial design.
The authors have added this as future lines of research.
The inclusion criteria for the a) the care workers and b) the participant residents were not clearly laid out. Did they all have dementia? If so, what stage of dementia? What about BPSD? Did they have some level of BPSD at baseline?
Inclusion criteria for care workers have been included. In relation of participant residents, the authors did not consider the presence or absence of BPSD through the NPI scale as criteria for inclusion because some patients score low on the scale because the Psychotropic drugs has regulated their BPSD. Similarly, not only patients diagnosed with dementia were selected, since BPSDs can present as prodromal symptoms of the disease. In a healthy older person it may indicate early dementia or be a risk factor for the future development of dementia (Reyes-Figueroa et al., 2010; Van der Linde, Stephan, Savva, Dening & Brayne, 2012). What has been referred to as Mild Behavoural Impairment (MBI) (Ismail et al., 2016).
These sentences have been included.
Reyes-Figueroa, J. C., Rosich-Estragó, M., Bordas-Buera, E., Gaviria-Gómez, A. M., Vilella-Cuadrada, E. y Labad-Alquézar, A. (2010). Síntomas psicológicos y conductuales como factores de progresión a demencia tipo Alzheimer en el deterioro cognitivo leve. Revista de Neurología, 50 (11), 653-660. DOI: https://0-doi-org.brum.beds.ac.uk/10.33588/rn.5011.2009714.
Van Der Linde, R., Stephan, B., Savva, G., Dening, T. y Brayne, C. (2012). Systematic reviews on behavioural and psychological symptoms in the older or demented population. Alzheimer’s Research & Therapy, 4, 1-23. DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/alzrt131.
Ismail, Z., Smith, E. E., Geda, Y., Sultzer, D., Brodaty, H., Smith, G., Agüera-Ortiz, L., Sweet, R., Miller, D. y Lyketsos, C. G. (2016). Neuropsychiatric symptoms as early manifestations of emergent dementia: provisional diagnostic criteria for mild behavioral impairment. Alzheimer’s & Dementia, 12 (2), 195-202. DOI: https://0-doi-org.brum.beds.ac.uk/10.1016/j. jalz.2015.05.017
The capacity of residents to participate in the study was not discussed. This is a crucial ethical issue that needs a significant level of detail. Were families involved in the decision to participate? If residents had capacity at the beginning of the study, did any lose capacity during the study and how was this managed?
This aspect has been added in Method section (2.1. Participants)
Blinding of raters: No mention is made of blinding of raters to the intervention arm of the study. This is a significant flaw as significant bias will be introduced otherwise.
The authors have mentioned this aspect in Method section.
Consort diagram: The authors need to include a CONSORT diagram to make clear what numbers of residents were eligible, how many were approached, how many consented, how many passed screening etc.
The Consort Diagram has been added.
Outcomes: Why was the nursing home version of the NPI not used? This tool is more specific for the setting. Who were the informants for the NPI outcomes? If it was the care home workers who received the training, then the study design is significantly flawed. The informants AND raters need to be blind to the intervention.
The authors have explained the choice of this tool.
What was the primary outcome measure of interest? The authors list both cognitive and behavioural outcomes. Ideally there should be only one primary outcome, and, in a study of this size, it should be feasibility and/or acceptability of the intervention, not effectiveness.
Cognitive outcomes only have been presented as a test for homogeneity results. The primary outcome is a behavioural outcome.
Basis for the intervention: The theoretical basis for the intervention and the background, including field trialing of the intervention need to be discussed in more detail.
It has been added information about this question in the Introduction and the Discussion sections.
Intervention delivery and fidelity: The authors have not included any detail about the adherence of the staff to the teaching of the intervention. Indeed, no information about staff engagement with the intervention is included. Process measures are essential in a study of this type of intervention. This is lacking here.
The professionals who received training carried out satisfaction and follow-up questionnaires in order to assess their commitment to the implementation of the program as well as to evaluate difficulties.
We have added a comment on this aspect
There was no mention at all about the impact of the COVID-19 pandemic which has hit the care home sector particularly hard. If the study was done pre-COVID, then implications for this type of intervention in COVID or post-COVID era need to be mentioned.
The authors have mentioned the importance of the study for the current situation caused by COVID-19.
There is minimal description of the nursing home characteristics - were they similar? What was the model of care? What was staff training like? How were differences accounted for? etc.
Nursing home information has been added.
Minor issues
The authors may want to have their manuscript checked by a native English medical writer. Some of the terminology was non-standard.
Please refer to ‘people with dementia’ rather than ‘patients’; alternatively, they can be referred to as ‘residents’ since the nursing home is where they live.
The words have been changed.
Please refer to ‘participants’ in the study, not ‘subjects’. This is derogatory.
The sentence has been modified.
Please correct the referencing – when using a reference manager [x], author names should not appear, i.e. (Steppacher and Kissler, 2018)
The authors have deleted this reference.
This statement is very outdated ‘BPSD are treated mainly with psychotropic drugs (anxiolytics, antidepressants, 51antipsychotics...)’ few places these days would prioritise psychotropic medications over non-medication interventions (see Guidelines from most societies and national dementia strategies) – the authors should refer to these and cite the literature on this topic; they can then refer to the fact that in spite of these guidelines, bad practice of excess psychotropic use still exists in some care homes (citations needed).
The sentence has been rewritten.
Please do not use ‘…’ (i.e. antipsychotics...)
We have modified this sentence.
This statement is not accurate: ‘In this sense, one review [11] highlights the importance of non-pharmacological interventions against pharmacological interventions since they do not entail secondary effects, they imply a lower cost and have been shown to have positive effects’. In fact, there is a huge literature on the topic and the authors need to acknowledge this.
We have changed this statement.
This statement is very outdated as this view is the established one and has been around for many years: ‘A non-pharmacological intervention that is 59gaining more and more momentum is the one that views BPSD as an expression of unmet needs’.
The sentence has been deleted.
Author Response File: Author Response.doc
Reviewer 3 Report
- line 46: (Steppacher and Kissler, 2018) can be deleted as it corresponds to reference number 6.
- Line 101-105: The authors provide characteristics of the professional caregivers who received the training program, but they do not provide information about the caregivers in the control group. How many caregivers provided care in the CG, how old were these professionals, etc, and were these characteristics comparable to the EG? Moreover, I expect to find characteristics in the results section and not in the methods section.
- Lines 111-116: These lines describe results, please move these findings to the results section. In addition, first describe how many participants were excluded before describing the characteristics of the included participants.
- Line 124 The maximum score of the MMSE is 30 and not 35.
- Lines 129-130 and paragraph 3.3: More clarity is necessary on how the use of psychotropic drugs was measured. Did the authors count the number of psychotropic drugs in use per time period? Did they use ATC-codes? And were drugs prescribed on an ‘as needed’ basis also counted?
- Lines 206-209: There is a decrease in psychotropic drug use in the EG and an increase in the CG between T1 and T5. Which drug class(es) was/were responsible for the decrease and increase? Please discuss this point in the Discussion as well.
- Line 220: Can the authors provide a possible explanation for the increase in BPSD in the control group? Was the control group aware of the aim and hypothesis of the study?
Author Response
- line 46: (Steppacher and Kissler, 2018) can be deleted as it corresponds to reference number 6.
The authors have deleted this reference.
- Line 101-105: The authors provide characteristics of the professional caregivers who received the training program, but they do not provide information about the caregivers in the control group. How many caregivers provided care in the CG, how old were these professionals, etc, and were these characteristics comparable to the EG? Moreover, I expect to find characteristics in the results section and not in the methods section.
The authors have described the characteristics of CG and have organized the information in Results section.
- Lines 111-116: These lines describe results, please move these findings to the results section. In addition, first describe how many participants were excluded before describing the characteristics of the included participants.
The authors have organized the information.
- Line 124 The maximum score of the MMSE is 30 and not 35.
In the Spanish version (Lobo et al., 2002), the maximum score is 35 points.
- Lines 129-130 and paragraph 3.3: More clarity is necessary on how the use of psychotropic drugs was measured. Did the authors count the number of psychotropic drugs in use per time period? Did they use ATC-codes? And were drugs prescribed on an ‘as needed’ basis also counted?
The authors have explained how they measured the consumption of psychotropic drugs in this study
- Lines 206-209: There is a decrease in psychotropic drug use in the EG and an increase in the CG between T1 and T5. Which drug class(es) was/were responsible for the decrease and increase? Please discuss this point in the Discussion as well.
In Discussion section it has been added an explanation about this question.
- Line 220: Can the authors provide a possible explanation for the increase in BPSD in the control group? Was the control group aware of the aim and hypothesis of the study?
The authors have explained the increase in BPSD in the Control group
Round 2
Reviewer 1 Report
International Journal of Environmental Research and Public Health
Effects of an educational program for professional caregivers on behavioural alterations in nursing home residents: pilot study
General comments
Thank you to the authors for thoroughly addressing the reviewer comments. These have helped to strengthen the paper and the evidence presented. Please make sure to have a good read through to address all grammatical errors. See some additional comments included below.
Specific comments
Abstract
P 1-L14 – please change 145 to One hundred and forty-five if this is included at the start of the sentence. This should be the same for 22.
P 1 – L16 – please remove the word ‘to’ and replace with ‘in the’ and include ’20 h’ before training program.
P 1 – L17 – please change ‘five measures’ to something along the lines of ‘five data collection points (pre and post and three follow-ups all 6 months apart). In the abstract there is still inconsistency about the length of time the intervention and follow-ups occurred during the study.
P1 – L 28 – I can see what the authors are getting at here but I think this sentence needs to be rephrased slightly. The ‘new alternatives’ is based on an ‘education intervention’ – could this be incorporated here?
Introduction
P 2 - L81 – please change ‘other’ to ‘another’ and make sure the information presented in this sentence is clear. Is it an intervention or just Cohen-Mansfield recommendations of ‘unmet needs?’ I think this could be phrased better here.
P 3 – L103 – please place ‘an’ between ‘effects of’ and ‘educational program’
Methods
Participants
P 3 – L 127 place the word ‘the’ between ‘left’ and ‘nursing home’
P 4 – L 144 – change ‘did not’ to ‘was not’ and place the word ‘of’ between ‘because’ and ‘the’ and remove the word ‘has’
P 4 – L 152 remove the word ‘to’ between ‘know’ and ‘which’
P 4 – L 153 change control group to CG. Please make sure this is consistent throughout the manuscript.
P 4 – L 164 – please clarify on who was providing informed consent. Did this include the individuals with dementia? If so, this causes some issues with regards to their cognitive capacity to consent. Or did the family members consent and those with dementia provide assent?
Procedure
P 5 – L 298 – please see the comment above regarding consent. This information only needs to be presented once in the manuscript but also needs to be clear who were able to sign the consent forms.
P 5 – L 200 – change ‘treat’ to ‘treated’
Discussion
P 7 – L 291 – please rephrase opening sentence.
P 7 – L 294 – place the word ‘an’ between ‘of’ and ‘educational’
P 7 – L 295 – please rephrase ‘the program type decrease in BPSD’
P 8 – L 305 please rephrase this section there are a number of grammatical errors
Overall, the authors have made some changes to the discussion. However restructuring some of the paragraphs and the information presented would help to strengthen ‘why’ the results are important. For example, the use of psychotropic drugs was a positive finding from this study, however more information and a stronger link as to why this is important needs to be included here.
Paragraphs starting P 8 - L 329 to L 350 –this information could be combined and written more succinctly, and then conclude with why this study may help to address some of these issues?
P 8 - L 362 – L366 – could this be one paragarph? Again think about the results from this study and how this may link to the literature currently published. Come back to why this study is important.
Lastly, the level of BPSD was significant between CG/EG for time point 1 and time point 5. However every little discussion on this has been included here (P 8 – L314). Therefore, could the authors not suggest that this change in BPSD is the result of an education intervention and a key finding for this study? And is this not sustained/show a long term effect as approximately a year and half later (difference between T1 and T5?) This should be highlighted in this section.
Limitations
Thank you for the authors acknowledging that further follow up on training following the completion of the study could have been done.
Author Response
General comments
Thank you to the authors for thoroughly addressing the reviewer comments. These have helped to strengthen the paper and the evidence presented. Please make sure to have a good read through to address all grammatical errors. See some additional comments included below.
Specific comments
Abstract
P 1-L14 – please change 145 to One hundred and forty-five if this is included at the start of the sentence. This should be the same for 22.
This aspect has been changed
P 1 – L16 – please remove the word ‘to’ and replace with ‘in the’ and include ’20 h’ before training program.
According to the reviewer has been replaced “to” for “in the” and included ’20 h’ before training program.
P 1 – L17 – please change ‘five measures’ to something along the lines of ‘five data collection points (pre and post and three follow-ups all 6 months apart). In the abstract there is still inconsistency about the length of time the intervention and follow-ups occurred during the study.
The sentence has been rephrase
P1 – L 28 – I can see what the authors are getting at here but I think this sentence needs to be rephrased slightly. The ‘new alternatives’ is based on an ‘education intervention’ – could this be incorporated here?
According to the reviewer has been incorporated education intervention’ in this sentence
Introduction
P 2 - L81 – please change ‘other’ to ‘another’ and make sure the information presented in this sentence is clear. Is it an intervention or just Cohen-Mansfield recommendations of ‘unmet needs?’ I think this could be phrased better here.
The authors has been changed “other” and have clarified that ‘unmet needs is other option or methodologies
P 3 – L103 – please place ‘an’ between ‘effects of’ and ‘educational program’
It has been added
Methods
Participants
P 3 – L 127 place the word ‘the’ between ‘left’ and ‘nursing home’
It has been replaced
P 4 – L 144 – change ‘did not’ to ‘was not’ and place the word ‘of’ between ‘because’ and ‘the’ and remove the word ‘has’
This changes has been made
P 4 – L 152 remove the word ‘to’ between ‘know’ and ‘which’
This word has been removed
P 4 – L 153 change control group to CG. Please make sure this is consistent throughout the manuscript.
The authors have replaced “‘control group” for “CG” and have verified this question throughout the manuscript.
P 4 – L 164 – please clarify on who was providing informed consent. Did this include the individuals with dementia? If so, this causes some issues with regards to their cognitive capacity to consent. Or did the family members consent and those with dementia provide assent?
According to the reviewer this information only presented in procedure section and have been clarified who were able to sign the consent forms.
Procedure
P 5 – L 298 – please see the comment above regarding consent. This information only needs to be presented once in the manuscript but also needs to be clear who were able to sign the consent forms.
According to the reviewer this information only presented in procedure section and have been clarified who were able to sign the consent forms.
P 5 – L 200 – change ‘treat’ to ‘treated’
This change has been made
Discussion
P 7 – L 291 – please rephrase opening sentence.
The opening sentence has been rephrase
P 7 – L 294 – place the word ‘an’ between ‘of’ and ‘educational’
It has been replaced
P 7 – L 295 – please rephrase ‘the program type decrease in BPSD’
The sentence has been rephrase
P 8 – L 305 please rephrase this section there are a number of grammatical errors
The authors have reviewed this section
Overall, the authors have made some changes to the discussion. However restructuring some of the paragraphs and the information presented would help to strengthen ‘why’ the results are important. For example, the use of psychotropic drugs was a positive finding from this study, however more information and a stronger link as to why this is important needs to be included here.
The authors have added information to make the idea clearer
Paragraphs starting P 8 - L 329 to L 350 –this information could be combined and written more succinctly, and then conclude with why this study may help to address some of these issues?
The authors have modified the structure of these paragraphs to highlight the findings
P 8 - L 362 – L366 – could this be one paragarph? Again think about the results from this study and how this may link to the literature currently published. Come back to why this study is important.
The authors have added information to highlight the findings
Lastly, the level of BPSD was significant between CG/EG for time point 1 and time point 5. However every little discussion on this has been included here (P 8 – L314). Therefore, could the authors not suggest that this change in BPSD is the result of an education intervention and a key finding for this study? And is this not sustained/show a long term effect as approximately a year and half later (difference between T1 and T5?) This should be highlighted in this section.
The authors have highlighted this aspect
Limitations
Thank you for the authors acknowledging that further follow up on training following the completion of the study could have been done.
Author Response File: Author Response.doc
Reviewer 2 Report
The authors have addressed several comments and the paper is now substantially improved; however, the basic study design is still weak (not clustered; no blinding of outcome raters etc) thus the result must be interpreted with extreme caution.
I suggest making a much stronger case for 'limitations' and really stress 'next steps' and how a better designed definitive study needs to follow this one.
Please revise the language use again - there are still subtle errors in word use and grammar.
Thank you to the authors for their hard work on this.
Author Response
The authors have addressed several comments and the paper is now substantially improved; however, the basic study design is still weak (not clustered; no blinding of outcome raters etc) thus the result must be interpreted with extreme caution.
The authors have added that these aspects of the design must be improved in future studies in order to generalize the results of this pilot study.
I suggest making a much stronger case for 'limitations' and really stress 'next steps' and how a better designed definitive study needs to follow this one.
Please revise the language use again - there are still subtle errors in word use and grammar.
Thank you to the authors for their hard work on this.
Author Response File: Author Response.docx
