Nonpharmacological therapies in Alzheimer's disease: a systematic review of efficacy

INTRODUCTION

Nonpharmacological therapies (NPTs) can improve the quality of life (QoL) of people with Alzheimer's disease (AD) and their carers. The objective of this study was to evaluate the best evidence on the effects of NPTs in AD and related disorders (ADRD) by performing a systematic review and meta-analysis of the entire field.

METHODS

Existing reviews and major electronic databases were searched for randomized controlled trials (RCTs). The deadline for study inclusion was September 15, 2008. Intervention categories and outcome domains were predefined by consensus. Two researchers working together detected 1,313 candidate studies of which 179 RCTs belonging to 26 intervention categories were selected. Cognitive deterioration had to be documented in all participants, and degenerative etiology (indicating dementia) had to be present or presumed in at least 80% of the subjects. Evidence tables, meta-analysis and summaries of results were elaborated by the first author and reviewed by author subgroups. Methods for rating level of evidence and grading practice recommendations were adapted from the Oxford Center for Evidence-Based Medicine.

RESULTS

Grade A treatment recommendation was achieved for institutionalization delay (multicomponent interventions for the caregiver, CG). Grade B recommendation was reached for the person with dementia (PWD) for: improvement in cognition (cognitive training, cognitive stimulation, multicomponent interventions for the PWD); activities of daily living (ADL) (ADL training, multicomponent interventions for the PWD); behavior (cognitive stimulation, multicomponent interventions for the PWD, behavioral interventions, professional CG training); mood (multicomponent interventions for the PWD); QoL (multicomponent interventions for PWD and CG) and restraint prevention (professional CG training); for the CG, grade B was also reached for: CG mood (CG education, CG support, multicomponent interventions for the CG); CG psychological well-being (cognitive stimulation, multicomponent interventions for the CG); CG QoL (multicomponent interventions for PWD and CG).

CONCLUSION

NPTs emerge as a useful, versatile and potentially cost-effective approach to improve outcomes and QoL in ADRD for both the PWD and CG.

Teaching Tai Chi to elders with osteoarthritis pain and mild cognitive impairment

This article describes the authors' experience and strategies in teaching Tai Chi, a gentle exercise derived from an ancient Chinese martial art, to mildly cognitively impaired elders to relieve osteoarthritic knee pain. The 12-form Sun-style Tai Chi, a set of Tai Chi forms endorsed by the American Arthritis Foundation, was used in the program. Teaching Tai Chi to elders with mild cognitive impairment requires particular strategies tailored to their physical and cognitive frailty. When effectively taught, Tai Chi can be a unique and cost-effective intervention for elders with knee pain caused by osteoarthritis.

[Energy and memory efficient calculation of the accommodation demand in the artificial accommodation system]

Presbyopia and cataract are gaining more and more importance in the ageing society. Both age-related complaints are accompanied with a loss of the eye's ability to accommodate. A new approach to restore accommodation is the Artificial Accommodation System, an autonomous micro system, which will be implanted into the capsular bag instead of a rigid intraocular lens. The Artificial Accommodation System will, depending on the actual demand for accommodation, autonomously adapt the refractive power of its integrated optical element. One possibility to measure the demand for accommodation non-intrusively is to analyse eye movements. We present an efficient algorithm, based on the CORDIC technique, to calculate the demand for accommodation from magnetic field sensor data. It can be shown that specialised algorithms significantly shorten calculation time without violating precision requirements. Additionally, a communication strategy for the wireless exchange of sensor data between the implants of the left and right eye is introduced. The strategy allows for a one-sided calculation of the demand for accommodation, resulting in an overall reduction of calculation time by 50 %. The presented methods enable autonomous microsystems, such as the Artificial Accommodation System, to save significant amounts of energy, leading to extended autonomous run-times.

Nasal vascular hamartoma in a Domestic Shorthair cat

A nasal mass in a Domestic Shorthair cat was causing facial deformity, sneezing and intermittent epistaxis. Biopsy samples obtained previously had been non-diagnostic. Computed tomography images revealed an irregular, contrast-enhancing mass occupying a large portion of the righthand side of the nasal cavity. Previously described criteria for malignancy were not present. A ventral surgical approach combined with temporary, ipsilateral, common carotid arterial occlusion provided excellent access for debulking the lesion and collecting samples for histopathology. A nasal vascular hamartoma was diagnosed and clinical signs resolved postoperatively. This is the first documentation of this abnormality in the cat. Hamartomatous abnormalities should be included on the list of differential diagnoses for feline nasal mass lesions. The prognosis for hamartomatous lesions postoperatively is good, in keeping with their limited propensity for growth after maturity.

The Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders (PBOICIE)

Older adults with severe cognitive impairment have trouble responding to questions about their osteoarthritis knee or hip pain, which makes pain management difficult. Therefore, the Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders (PBOICIE) was developed as an alternative. This article reports the development and psychometric testing of the PBOICIE in three studies. The 6-item PBOICIE was not associated with the Verbal Descriptor Scale but was significantly associated with Keefe's method for observing pain behaviors in patients with knee osteoarthritis, with r=0.36 to 0.55, indicating good concurrent validity. The 6-item PBOICIE was able to discriminate older adults' pain behaviors before and after administration of an analgesic agent (2.9+/-1.89 versus 1.97+/-1.98; p<0.001). This study has shown that multifaceted pain assessments are needed in older adults with osteoarthritis knee or hip pain, as the observed behaviors did not parallel but added information to verbal report.

Teaching Tai Chi to elders with osteoarthritis pain and mild cognitive impairment

This article describes the authors' experience and strategies in teaching Tai Chi, a gentle exercise derived from an ancient Chinese martial art, to mildly cognitively impaired elders to relieve osteoarthritic knee pain. The 12-form Sun-style Tai Chi, a set of Tai Chi forms endorsed by the American Arthritis Foundation, was used in the program. Teaching Tai Chi to elders with mild cognitive impairment requires particular strategies tailored to their physical and cognitive frailty. When effectively taught, Tai Chi can be a unique and cost-effective intervention for elders with knee pain caused by osteoarthritis.

Interactions of motion and form in visual cortex - A neural model

In this work, we present a neural model simulating parts of the motion and the form pathway of the visual cortex. It is shown how the visual features motion, disparity, and form that are represented in a distributed way in areas V1, V2, and MT mutually interact at several levels. Thus, their information is shared without the need of explicit neural representation for each combination of features. In particular, we address the issue of 2D extrinsic motion cues generated at occlusions that have to be treated differently than 2D intrinsic motion features of the same object. We suggest that here information of the form channel, namely the indication of a junction, is necessary to achieve a correct percept in the motion pathway. Furthermore, we investigated the question of how a percept of either pattern or component motion is generated in a scenario of moving bars that only differs in the presence or absence of occlusions, like in the chopstick and the barberpole display. We propose different roles for various kinds of MT cells that are involved in the interactions with the form pathway, simulating purely integrative cells tuned to motion and to motion and stereo, but also contrast cells responding strongly when motion in the surround is in the opposite direction. The model simulations reproduce psychophysical and neurophysiological results of the chopstick as well as of the barberpole illusion. The temporal course of the dominant motion percept generated by the iterative interplay between motion and form pathway is in line with data of ocular following responses in primates and humans.

Enrolling older adults with cognitive impairment in research: lessons from a study of Tai Chi for osteoarthritis knee pain

Exercise is an adjunct intervention for treating osteoarthritis (OA) knee pain, but many older adults, especially those with cognitive impairment, refuse to participate because of their frailty. Tai chi is a gentle alternative to Western-style aerobic exercise. In this article, we report recruitment experiences based on older adults' comments and on staff's observations and reports in a pilot randomized controlled trial (RCT) using tai chi as an intervention to reduce OA knee pain in a population of older adults with cognitive impairment. Recruitment challenges included issues with retirement apartment site staff, the older adults, study criteria or study design, and insufficient research staff. Strategies included networking and staying connected with site staff, using various recruiting approaches, providing incentives/motivation, and using informal leaders or residents as a way to recruit participants. Finally, modifying strict study criteria, securing staff for recruiting, and considering alternative designs to the classical RCT can also help overcome recruitment challenges.

Factors associated with aggressive behavior among nursing home residents with dementia

PURPOSE

In an attempt to more thoroughly describe aggressive behavior in nursing home residents with dementia, we examined background and proximal factors as guided by the Need-Driven Dementia-Compromised Behavior model.

DESIGN AND METHODS

We used a multivariate cross-sectional survey with repeated measures; participants resided in nine randomly selected nursing homes within four midwestern counties. The Minimum Data Set (with verification by caregivers) identified participants. We used a disproportionate probability sample of 107 participants (51% with a history of aggressive behavior) to ensure variability. Videotaped care events included four of direct care (shower baths, meals, dressing, and undressing) and two of nondirect care (two randomly selected 20-minute time periods in the afternoon and evening). The majority of participants (75%) received three shower baths, for a total of 282 videotaped baths.

RESULTS

Because the shower bath was the only care event significantly related to aggressive behavior (F = 6.9, p < .001), only those data are presented. Multilevel statistical modeling identified background factors (gender, mental status score, and lifelong history of less agreeableness) and a proximal factor (amount of nighttime sleep) as significant predictors (p < .05) of aggressive behavior during the shower bath. We found significant correlations between aggressive behavior and negative subject affect (r = .27) during the bath, and aggressive behavior and lifetime agreeableness level (r = -.192). We also found significant correlations between mental status and the amount of education (r = .212), and between negative caregiver affect and negative participant affect (r = .321).

IMPLICATIONS

We identified three background and one proximal factor as significant risk factors for aggressive behavior in dementia. Data identify not only those persons most at risk for aggressive behavior during care, but also the care event most associated with aggressive behavior. Together these data inform both caregiving for persons with dementia as well as the design of intervention studies for aggressive behavior in dementia.

Improving dementia care in assisted living residences: addressing staff reactions to training

More than 1 million older adults, many with significant cognitive impairment, receive care in assisted living residences (ALRs), and their numbers are increasing. Despite this, ALR staff are often inadequately trained to manage the complex emotional, behavioral, and functional impairments characteristic of these residents. Nurses are in a unique position to improve this situation by training and supervising ALR staff. To facilitate such training, an understanding of staff reactions to receiving training as well as a systematic yet flexible method for training is needed. This article provides information on one such program (STAR-Staff Training in Assisted-living Residences), discusses challenges that arose when offering this program across 3 states in 6 diverse ALRs (rural, urban, for-profit, and not-for-profit sites), and describes how these challenges were addressed. We illustrate how nurses can successfully train ALR staff to improve resident and staff outcomes and offer guidance for those interested in providing such training.

Intervention research in highly unstable environments

This article highlights issues and presents strategies for conducting intervention research in highly unstable environments such as schools, critical care units, and long-term care facilities. The authors draw on their own experiences to discuss the challenges that may be encountered in highly unstable settings. The concept of validity provides a framework for understanding the value of addressing the many methodological issues that can emerge in settings characterized by instability. We explain unstable environments by elaborating on knowable elements that contribute to instability. Strategies are provided for improving success of intervention research in unstable settings by carrying out an environmental assessment prior to beginning a study.

Neurosurgical aspects of childhood hypophosphatasia

OBJECTIVE

Hypophosphatasia (HPP; MIM241510) is a rare inborn error of bone metabolism of recessive inheritance. It is caused by mutations in the gene encoding the tissue-nonspecific alkaline phosphatase. Apart from problems in bone mineralization, growth failure, and premature loss of decidual teeth, the infantile and the childhood types of HPP are associated with premature fusion of cranial sutures.

PATIENTS

We report on seven children affected with infantile and childhood HPP who presented with craniosynostosis.

RESULTS

Neurosurgical intervention was necessary in four of them because of intracranial hypertension. In one of these, severe dural calcification posed an unexpected problem during surgery. Secondary ectopia of the cerebellar tonsils were detected in five of the seven patients and caused hydrosyringomyelia in one of them.

CONCLUSIONS

Since cranial sutures are frequently involved in infantile and childhood HPP, a multidisciplinary approach for the clinical care is necessary, including long-term neurosurgical surveillance.

The Feasibility of Implementing Tai Chi for Nursing Home Residents With Knee Osteoarthritis and Cognitive Impairment

This paper addresses the feasibility of implementing Tai Chi (TC) as an intervention for nursing home residents with osteoarthritis knee and cognitive impairment (CI). Recruiting elderly residents to participate was difficult. Only 9 out of the 31 originally thought eligible meet study criteria and 8 of the 9 elders eventually completed the study. With 2 sessions per week, the elders needed 8-10 weeks to learn the complete set of TC. They could not memorize the TC sequences, but they could follow the instructor who also employed verbal and visual cueing during the intervention. Clearly, elders with CI need different teaching methods and doses of TC. Using extended TC and teaching strategies tailored to participants' physical and cognitive capacity may promote effective learning.