Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies, 1998-2008: a systematic literature review

Cognitive impairment and cardiovascular disease: so near, so far

In the spectrum of cognitive impairment, ranging from "pure" vascular dementia to Alzheimer's disease (AD), clinical interest has recently expanded from the brain to also include the vessels, shifting the pathophysiological focus from the leaves of synaptic dysfunction to the sap of cerebral microcirculation and the roots of cardiovascular function. From a diagnostic viewpoint, a thorough clinical evaluation of individuals presenting cognitive impairment might systematically include the assessment of the major cardiovascular rings of the chain linking regional perfusion to brain function: 1) lung (with assessment of asthma, chronic obstructive pulmonary disease, obstructive sleep apnea syndrome); 2) heart function (with clinical examination and echocardiography) and cardiovascular risk factors; 3) orthostatic hypotension (with medical history and measurement of heart rate and blood pressure in supine and upright positions); 4) aorta and large artery stiffness (with assessment of pulse wave velocity); 5) large cerebro-vascular vessel status (with neuroimaging techniques); 6) assessment of microcirculation (with cerebrovascular reactivity testing with transcranial Doppler sonography or MRI perfusion imaging); and 7) assessment of venous cerebral circulation. The apparent difference in approaches to "brain" and "vascular" environmental enrichment with physical, cognitive and sensorial training is conceptually identical to that of a constant gardener caring for an unhealthy tree, watering the leaves ("train the brain") or simply the roots ("mind the vessel"). The therapeutic difference probably consists in the amount and quality of water added to the tree, rather than by where one pours it, with either a top-down (leaves to roots) or bottom-up (roots to leaves) approach.

Interventions targeting pain or behaviour in dementia: a systematic review

BACKGROUND

Both pain and challenging behaviour are highly prevalent in dementia, and multiple studies show that some of these behaviours may be correlated. Pain, especially in non-communicative patients, can cause challenging behaviour, and treatment of pain therefore may have an effect on behaviour. This review aims to provide a comprehensive overview of the current state of evidence regarding the effectiveness of interventions targeting pain on the outcome behaviour, and interventions targeting behaviour on pain, in dementia.

METHOD

PubMed (MEDLINE), EMBASE, COCHRANE, CINAHL, PsychINFO and Web of Science were searched systematically. Studies were included if they focused on an intervention targeting a reduction in the person's distress, pain, and/or behaviour, and included adults with a main diagnosis of dementia.

RESULTS

Of a total of 893 potentially relevant publications that were identified, 16 publications met the inclusion criteria and were eligible for further analysis; 6 studies focused on a pain intervention targeting behaviour, 1 study focused on a behavioural intervention targeting pain, and 9 studies focused on an intervention targeting both pain and behaviour.

CONCLUSION

Available evidence suggests that (pain) interventions targeting behaviour, and (behavioural) interventions targeting pain are effective in reducing pain and behavioural symptoms in dementia.

Psychopharmacological medication use among older adults with dementia in nursing homes

Historically, the use of psychopharmacological medications, such as antipsychotic, antidepressant, and anxiolytic agents, have been scrutinized due to concerns with safety and efficacy especially in older adults with dementia. Over the past year, the Centers for Medicare & Medicaid Services launched a national initiative to improve the behavioral health of older adults residing in America's nursing homes with a focus on reducing the inappropriate use of these medications to inform the practitioner of the importance of not just evaluating antipsychotic agents but all medications that an older person with dementia may be prescribed. This is critical due to the increased vulnerability of this population to adverse effects coupled with varying degrees of efficacy. Online national resources are also provided.

Animal-Assisted Intervention in Dementia

There is a need to develop nonpharmacological treatments and methods which can serve as alternatives or complements to medications in dementia care. Previous research indicates that animal-assisted intervention (AAI) can be beneficial. The purpose of the present pilot project was to evaluate effects of AAI on quality of life (QoL) in people with dementia in four Swedish nursing homes. A pretest/posttest research design was used. Twenty people (12 women, 8 men; aged 58 to 88) were included. Nine people completed the intervention which comprised 10 training sessions with a certified therapy dog team. QoL improved in the expected direction after the intervention ( p = .035). Even though the effects of AAI may not be discernible over longer periods of time, there are still immediate effects which can promote better QoL for people living with dementia diseases.

Inappropriate use of psychotropic drugs in older individuals: implications for practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Effectiveness of a multifaceted implementation strategy on physicians' referral behavior to an evidence-based psychosocial intervention in dementia: a cluster randomized controlled trial

BACKGROUND

To evaluate the effectiveness of a multifaceted implementation strategy on physicians' referral rate to and knowledge on the community occupational therapy in dementia program (COTiD program).

METHODS

A cluster randomized controlled trial with 28 experimental and 17 control clusters was conducted. Cluster included a minimum of one physician, one manager, and two occupational therapists. In the control group physicians and managers received no interventions and occupational therapists received a postgraduate course. In the experimental group physicians and managers had access to a website, received newsletters, and were approached by telephone. In addition, physicians were offered one outreach visit. In the experimental group occupational therapists received the postgraduate course, training days, outreach visits, regional meetings, and access to a reporting system. Main outcome measure was the number of COTiD referrals received by each cluster which was assessed at 6 and 12 months after the start of the intervention. Referrals were included from both participating physicians (enrolled in the study and received either the control or experimental intervention) and non-participating physicians (not enrolled but of whom referrals were received by participating occupational therapists). Mixed model analyses were used to analyze the data. All analyses were based on the principle of intention-to-treat.

RESULTS

At 12 months experimental clusters received significantly more referrals with an average of 5,24 referrals (SD 5,75) to the COTiD program compared to 2,07 referrals in the control group (SD 5,14). The effect size at 12 months was 0.58. Although no difference in referral rate was found for the physicians participating in the study, the number of referrals from non-participating physicians (t -2,55 / 43 / 0,02) differed significantly at 12 months.

CONCLUSION

Passive dissemination strategies are less likely to result in changes in professional behavior. The amount of physicians exposed to active strategies was limited. In spite of this we found a significant difference in the number of referrals which was accounted for by more referrals of non-participating physicians in the experimental clusters. We hypothesize that the increase in referrals was caused by an increase in occupational therapists' efforts to promote their services within their network.

TRIAL REGISTRATION

NCT01117285.

Individual music therapy for agitation in dementia: an exploratory randomized controlled trial

OBJECTIVES

Agitation in nursing home residents with dementia leads to increase in psychotropic medication, decrease in quality of life, and to patient distress and caregiver burden. Music therapy has previously been found effective in treatment of agitation in dementia care but studies have been methodologically insufficient. The aim of this study was to examine the effect of individual music therapy on agitation in persons with moderate/severe dementia living in nursing homes, and to explore its effect on psychotropic medication and quality of life.

METHOD

In a crossover trial, 42 participants with dementia were randomized to a sequence of six weeks of individual music therapy and six weeks of standard care. Outcome measures included agitation, quality of life and medication.

RESULTS

Agitation disruptiveness increased during standard care and decreased during music therapy. The difference at -6.77 (95% CI (confidence interval): -12.71, -0.83) was significant (p = 0.027), with a medium effect size (0.50). The prescription of psychotropic medication increased significantly more often during standard care than during music therapy (p = 0.02).

CONCLUSION

This study shows that six weeks of music therapy reduces agitation disruptiveness and prevents medication increases in people with dementia. The positive trends in relation to agitation frequency and quality of life call for further research with a larger sample.

Nonpharmacologic management of behavioral symptoms in dementia

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behaviors can accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, and result in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case, we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction.

Improving quality of life for people with dementia in care homes: making psychosocial interventions work

BACKGROUND

Psychosocial interventions can improve behaviour and mood in people with dementia, but it is unclear how to maximise their effectiveness or acceptability in residential settings.

AIMS

To understand what underlies the successful implementation of psychosocial interventions in care homes.

METHOD

Systematic review and meta-synthesis of qualitative research.

RESULTS

The synthesis of 39 qualitative papers revealed that beneficial psychosocial interventions met the needs of people with dementia to connect with others, make a meaningful contribution and reminisce. Successful implementation rested on the active engagement of staff and family and the continuing provision of tailored interventions and support. This necessitated staff time, and raised issues around priorities and risk, but ultimately helped redefine staff attitudes towards residents and the caregiving role.

CONCLUSIONS

The findings from the meta-synthesis can help to inform the development and evaluation of psychosocial interventions in care homes and support their widespread implementation in clinical settings.

Behavioral disturbance in dementia

Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.

The effect of exercise on behavioral and psychological symptoms of dementia: towards a research agenda

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are common and are core symptoms of the condition. They cause considerable distress to the person with dementia and their carers and predict early institutionalization and death. Historically, these symptoms have been managed with anxiolytic and antipsychotic medication. Although potentially effective, such medication has been used too widely and is associated with serious adverse side-effects and increased mortality. Consequently, there is a need to evaluate non-pharmacological therapies for behavioral and psychological symptoms in this population. One such therapy is physical activity, which has widespread health benefits. The aim of this review is to summarize the current findings of the efficacy of physical activity on BPSD.

METHOD

Published articles were identified using electronic and manual searches. Rather than systematically aggregating data, this review adopted a rapid critical interpretive approach to synthesize the literature.

RESULTS

Exercise appears to be beneficial in reducing some BPSD, especially depressed mood, agitation, and wandering, and may also improve night-time sleep. Evidence of the efficacy of exercise on improving other symptoms such as anxiety, apathy, and repetitive behaviors is currently weak or lacking.

CONCLUSION

The beneficial effect of exercise type, its duration, and frequency is unclear although some studies suggest that walking for at least 30 minutes, several times a week, may enhance outcome. The methodological shortcomings of current work in this area are substantial. The research and clinical implications of current findings are discussed.

The development of quality indicators to improve psychosocial care in dementia

BACKGROUND

The evidence for the effectiveness of psychosocial interventions in dementia care is growing but the implementation of available evidence is not automatic. Our objective was to develop valid quality indicators (QIs) for psychosocial dementia care that facilitate the implementation process in various countries and settings.

METHODS

A RAND-modified Delphi technique was used to develop a potential set of QIs. Two multidisciplinary, international expert panels were involved in achieving content and face validity. Consensus on the final set was reached after a conference meeting where a third panel of dementia experts discussed measurability and applicability of the potential set. A retrospective cohort study was conducted to study the feasibility of using the final set in day care centers, hospitals, and nursing homes in Spain and The Netherlands.

RESULTS

A total of 104 recommendations were selected from guidelines and systematic reviews and appraised for their contribution to improving the quality of dementia care by 49 dementia experts. Twenty-five experts attended the conference meeting and reached consensus on a set of 12 QIs representing the key elements of effective psychosocial care, such as shared decision-making and interventions tailored to needs and preferences. Data from 153 patient records showed that all but one QI subitem were applicable to all three settings in both countries.

CONCLUSION

Our multidisciplinary and multinational strategy resulted in a set of unique QIs that aims exclusively at assessing the quality of psychosocial dementia care. Following implementation, these QIs will assist dementia care professionals to individualize and tailor psychosocial interventions.

Guidelines for psychosocial interventions in dementia care: a European survey and comparison

OBJECTIVE

The effectiveness of psychosocial interventions in treating people with dementia and their carers is increasingly emphasised in the literature. Dementia guidelines should summarise the scientific evidence and best practice that is currently available, therefore, it should include recommendations for psychosocial interventions. The aims of our study were (1) to collate dementia guidelines from countries across Europe and to check whether they included sections about psychosocial interventions, and (2) to compare the methodological quality and the recommendations for specific psychosocial interventions in these guidelines.

METHODS

The European dementia guidelines were inventoried. The methodological quality of the guideline sections for psychosocial interventions was assessed with the (AGREE) Appraisal of Guidelines Research and Evaluation instrument. The recommendations for specific psychosocial interventions were extracted from each of these guidelines and compared.

RESULTS

Guidelines for psychosocial interventions were found in five of 12 countries. Guideline developers, methodological quality and appreciation of available evidence influenced the inclusion of psychosocial interventions in dementia guidelines from Germany, Italy, the Netherlands, Spain and the UK. The UK NICE SCIE guideline had the best methodological quality and included the most recommendations for psychosocial interventions. Physical activity and carer interventions were recommended the most across all guidelines.

CONCLUSION

The inclusion of psychosocial interventions in dementia guidelines is limited across Europe. High-quality guidelines that include psychosocial interventions and are kept up to date with the emerging evidence are needed. Throughout Europe, special attention to the implementation of evidence-based psychosocial care is needed in the next few years.

Knowledge of and attitudes toward nonpharmacological interventions for treatment of behavior symptoms associated with dementia: a comparison of physicians, psychologists, and nurse practitioners

PURPOSE OF THE STUDY

Behavior problems are common in nursing homes. Current guidelines recommend nonpharmacological interventions (NPHIs) as first-line treatment, but pharmacological regimens (PIs) continue to be used. Given differences in background and training of those who treat behavior problems in residents, we compared attitudes of physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) concerning PI and NPHI usage as well as knowledge of NPHIs.

DESIGN AND METHODS

One hundred and eight MDs, 36 PhDs, and 89 NPs responded to a web-based questionnaire that captured level of agreement with statements concerning treatment of behavior symptoms and familiarity with NPHIs.

RESULTS

NPs were the most favorable toward NPHIs. MDs were significantly more favorable to the use of PIs than were PhDs, with attitudes of NPs falling in between. All felt that NPHI usage should increase and that NPHIs should be implemented before using PIs but also believed that PIs work well for behavior problems. MDs had significantly lower knowledge of NPHIs than PhDs or NPs. Overall, NPHI knowledge was similar for PhDs and NPs, although they differed on their use of specific interventions.

IMPLICATIONS

As levels of knowledge and familiarity with NPHIs differed among providers, it is conceivable that all might benefit from training and experience with a wider range of NPHIs. Future studies might evaluate the impact of a uniform understanding of NPHI on communication and teamwork in nursing homes and examine ways to enhance a multidisciplinary approach that would allow for the tailoring and individualization that is required of successful interventions.

Effectiveness of Environment-Based Interventions for People With Alzheimer’s Disease and Related Dementias

A systematic review of evidence for the efficacy of environment-based interventions on the affect, behavior, and performance of people with Alzheimer’s disease and related dementias was conducted as part of the American Occupational Therapy Association’s Evidence-Based Literature Review Project. Thirty-three reports met inclusion criteria. Results suggest that ambient music, aromatherapy, and Snoezelen® are modestly effective in reducing agitation but do not consistently have long-term effects. Visually complex environments that give the illusion of barriers deter people from wandering to unsafe places but do not reduce the urge to wander. Evidence that bright light therapy can aid in regulating mood and the sleep–wake cycle and thus help people remain awake during the day is preliminary. Montessori-based programming can be useful in matching activities to the person’s remaining skills. Further research is needed to evaluate the long-term effect, contraindications, and best dosages of these interventions.

Sleep in dementia and caregiving--assessment and treatment implications: a review

BACKGROUND

The increasing prevalence of dementia will precipitate a significant burden in terms of the costs of caring for people with dementia over the next 30 years; sleep disturbances in dementia are an important factor contributing to this burden.

METHODS

We reviewed sleep disturbances in people with dementia and their carers and describe the various diagnostic, assessment and treatment strategies available to physicians in the management of this clinically significant problem.

RESULTS

Sleep disturbances in people with dementia and their carers (i) are highly prevalent; (ii) impact significantly on quality of life of both people with dementia and their carers; (iii) increase the rate of cognitive decline; and (iv) accelerate the breakdown of community-based care. The training of physicians in the assessment and treatment of sleep disturbances in dementia and caregiving is scant despite a wide range of assessment strategies and treatment approaches, which comprise both pharmacological (including hypnotic/sedative medications) and non-pharmacological approaches (including: environmental; psychobehavioral; exercise and activity; and multi-component interventions). Specific diagnostic criteria for sleep disturbances in people with dementia and their carers remain lacking despite established criteria for general insomnia. Further to this, proposed changes to diagnostic criteria for DSM-V do not include a specific focus for the diagnosis and management of sleep disturbances in people with dementia or their carers.

CONCLUSIONS

This review suggests that the improved training of physicians to meet the needs of these vulnerable groups of older people is a priority, especially in the context of a rapidly increasing demand for accurate, early diagnosis and efficient management of sleep disturbance in these groups.

An update on the diagnosis and management of dementing conditions

Worsening memory is a common complaint in the elderly and predictably causes affected individuals and their families to wonder whether the underlying cause is Alzheimer disease, the most common form of dementia. Alzheimer disease is a devastating illness that unavoidably leads to a complete loss of independence and, as a result, substantial emotional, physical, and financial distress for patients and their families. The causes and severity of memory impairment in the elderly are diverse, however, so any given case might not necessarily be secondary to a neurodegenerative disorder such as Alzheimer disease. Consequently, it is critical to rule out potentially reversible causes of dementia and to initiate treatment while cognitive and functional deficits are still mild and more likely to respond to treatment. Furthermore, identifying the etiology and defining a suitable treatment plan early in the course of dementia allows patients to be more actively involved in the management of their disease and is more likely to improve quality of life for both patients and caregivers. This review presents the etiology of dementia in the elderly, describes the diagnostic process, and discusses current therapeutic strategies, including pharmacological agents, nonpharmacological interventions, safety assessments, legal issues, and caregiver needs.

Reactions of persons with dementia to caregivers singing in morning care situations

’Music therapeutic caregiving’, when caregivers sing for or together with persons with severe dementia during care situations, has been suggested as a way to reduce problematic behaviors in dementia care. The present study implemented this technique as an intervention in dementia care. Six caregivers participated in group interviews about their experiences of morning care situations without and with’Music therapeutic caregiving’. Through a qualitative content analysis two themes emerged.’Being in a different reality’ was based on’usual’ morning care situations. The caregivers’ experienced the persons with dementia as absent-minded; communication and cooperation were difficult. The second theme,’Being present’, was based on morning care situations with the intervention. The caregivers described communication as enhanced; the persons with dementia expressed themselves more appropriately, making cooperation possible. The results indicate that’Music therapeutic caregiving’ might lead to a more positive experience of the person with dementia and seems to increase receptivity to caregiving.

Top cited papers in International Psychogeriatrics: 6b. Behavioral disorders and caregivers' reaction in Taiwanese patients with Alzheimer's disease

The behavioral and psychological symptoms of dementia (BPSD) are common and serious problems that affect the quality of life of the patients who experience such symptoms as well as their caregivers (Matsui et al., 2006). BPSD present a major challenge in the medical management of cognitively impaired patients. Our paper entitled “Behavioral disorders and caregivers’ reaction in Taiwanese patients with Alzheimer's disease” (hereafter referred to as the “paper”) (Fuh et al., 2001) has been cited widely, reflecting the importance of these clinical issues and the growing international interest in studies of BPSD.