Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia

Psychosocial and Environmental Treatment Approaches for Behavioral and Psychological Symptoms in Neurocognitive Disorders: an Update and Future Directions

Nearly all persons with dementia will exhibit behavioral and psychological symptoms (BPSD) at some point during the course of the disease. These symptoms often pose significant challenges for formal and informal caregivers, and their treatment is unclear. Current guidelines recommend implementing nonpharmacological interventions as the first-line approach to managing BPSD. Given the recent proliferation of research evaluating the use of nonpharmacological interventions for BPSD, there is a continuing need to reevaluate and synthesize the findings in this area. The current review examines the evidence for using psychosocial and environmental strategies, focusing on the past 3 years of research efforts and assessing how this research augments what is known from prior reviews. We conclude that the results in the recent literature concerning the efficacy of psychosocial and environmental treatment approaches to behavioral symptoms in dementia continue to be promising, yet results are also mixed. We recommend the consideration of music therapy and tailored activities when utilizing a nonpharmacological approach, as these appear particularly promising throughout the literature. We also find that multisensory stimulation and animal-assisted therapy warrant further evaluation. In contrast, in this and previous reviews, approaches such as bright light therapy and aromatherapy have consistently been shown to be ineffective and, thus, cannot be recommended with confidence based on the evidence. We discuss limitations of current research studies and make recommendations for future research in the area of psychosocial and environmental interventions for BPSD.

Targeting Functional Decline in Alzheimer Disease: A Randomized Trial

BACKGROUND

Alzheimer disease results in progressive functional decline, leading to loss of independence.

OBJECTIVE

To determine whether collaborative care plus 2 years of home-based occupational therapy delays functional decline.

DESIGN

Randomized, controlled clinical trial. (ClinicalTrials.gov: NCT01314950).

SETTING

Urban public health system.

PATIENTS

180 community-dwelling participants with Alzheimer disease and their informal caregivers.

INTERVENTION

All participants received collaborative care for dementia. Patients in the intervention group also received in-home occupational therapy delivered in 24 sessions over 2 years.

MEASUREMENTS

The primary outcome measure was the Alzheimer's Disease Cooperative Study Group Activities of Daily Living Scale (ADCS ADL); performance-based measures included the Short Physical Performance Battery (SPPB) and Short Portable Sarcopenia Measure (SPSM).

RESULTS

At baseline, clinical characteristics did not differ significantly between groups; the mean Mini-Mental State Examination score for both groups was 19 (SD, 7). The intervention group received a median of 18 home visits from the study occupational therapists. In both groups, ADCS ADL scores declined over 24 months. At the primary end point of 24 months, ADCS ADL scores did not differ between groups (mean difference, 2.34 [95% CI, -5.27 to 9.96]). We also could not definitively demonstrate between-group differences in mean SPPB or SPSM values.

LIMITATION

The results of this trial are indeterminate and do not rule out potential clinically important effects of the intervention.

CONCLUSION

The authors could not definitively demonstrate whether the addition of 2 years of in-home occupational therapy to a collaborative care management model slowed the rate of functional decline among persons with Alzheimer disease. This trial underscores the burden undertaken by caregivers as they provide care for family members with Alzheimer disease and the difficulty in slowing functional decline.

PRIMARY FUNDING SOURCE

National Institute on Aging.

State of the Art Review: Physical Activity and Older Adults

Physical activity is an important component of a healthy lifestyle for all adults and especially for older adults. Using information from the updated 2008 Physical Activity Guidelines, 3 dimensions of physical activity are identified for older adults. These include increasing aerobic activity, increasing muscle-strengthening activity, and reducing sedentary or sitting behavior. Although the overall goal of the physical activity recommendations is to prevent chronic diseases and conditions from developing, many older adults are already affected. Therefore, suggested types of physical activity are described for specific diseases and conditions that are designed to mediate the condition or prevent additional disability. Finally, barriers to participation in physical activity specific to older adults are described, and possible solutions offered. Encouraging older adults to continue or even start a physical activity program can result in major health benefits for these individuals.

Alzheimer's disease prevention: A way forward

This review proposes a more optimistic view of Alzheimer's disease (AD), in contrast to that contributed by the ageing of the population and the failure of potentially curative therapies (vaccines and others). Treatment failure is likely due to the fact that AD gestates in the brain for decades but manifests in old age. This review updates the concept of AD and presents the results of recent studies that show that primary prevention can reduce the incidence and delay the onset of the disease. Half of all cases of AD are potentially preventable through education, the control of cardiovascular risk factors, the promotion of healthy lifestyles and specific drug treatments. These approaches could substantially reduce the future incidence rate of this disease.

[Effectiveness of occupational therapy and other non-pharmacological therapies in cognitive impairment and Alzheimer's disease]

A review is presented on the existing knowledge about the usefulness of the occupational therapy in the non-pharmacological treatment of Alzheimer's disease. After conducting a literature search of the period 2010-2015, 25 articles that met the inclusion criteria were selected. The evidence obtained showed the efficiency and effectiveness of OT in delaying the progression of various disorders, especially when structured home OT programs are used. These programs should include aerobic and strengthening, sensory stimulation, and cognitive and memory training exercises based on learning without mistakes. These have shown benefits in the performance of activities of daily living, cognitive and emotional functioning. The importance is stressed of the combined and individual household level intervention and caregiver education. Finally, the need for more studies on the effectiveness of long-term sensory stimulation is highlighted.

A 3-arm randomized controlled trial on the effects of dance movement intervention and exercises on elderly with early dementia

Background

Dementia is characterized by a progressive decline and deterioration of brain regions such as memory, spatial navigation and language, along with disturbances in daily functioning. Non-pharmacological interventions that offer a holistic approach by targeting cognitive functioning, prognosis and the psychological and social effects of dementia require rigorous investigation. The well-established benefits of physical activity for cognitive functioning and psychological support in dementia have been observed with dance-movement intervention. There is substantial evidence that dance-movement interventions provide emotional and social advantages. Thus, a randomized controlled trial (RCT) is planned to investigate the positive effects of a dance movement intervention, compared with mild physical exercise, on the physical and psychological well-being of elderly Chinese individuals with early dementia.

Methods/Design

A 3-arm RCT with waitlist control design will be used in this study. Two hundred and one elderly participants with very mild to mild dementia will be screened and randomized into the following groups: (i) dance movement based intervention, (ii) stretching and exercise intervention and (iii) no intervention waitlist-control group. The two intervention groups will receive a 1-h intervention, twice a week, for 12 weeks. The participants will be assessed four times over the course of 12 months: baseline before randomization, post-intervention (3 months), 6 months from baseline and 12 months from baseline. The primary outcomes will be compared between assessment points and between groups on neuropsychiatric symptoms, psychosocial well-being and cognitive and daily functioning. Secondary outcomes will assess the changes in salivary cortisol levels and their relationships with the primary outcome measures.

Discussion

This study will provide substantial evidence of the efficacy of a dance-movement-based intervention in slowing down dementia progression, due to its ability to act as a buffer against decline and improve areas affected by dementia. We also anticipate an association between cortisol levels and the outcome measures. The further development of this intervention into a structural program may be warranted for early psychosocial support among elderly populations.

Trial registration

The trial has been registered in the Chinese Clinical Trial Registry (ChiCTR-IOR-15006541).

Redesigning systems of care for older adults with Alzheimer's disease

Best-practice models of dementia care have evolved from strategies focused on family caregivers to guidelines predicated on supporting the patient-caregiver dyad along the care continuum. These models have grown in complexity to encompass medical and team-based care that is designed to coordinate dementia care across settings and providers for a defined population of patients. Although there is evidence that the models can improve outcomes, they have not been widely adopted. Barriers to the models' increased adoption include workforce limitations, the cost of necessary practice redesign, and limited evidence of their potential cost-effectiveness. We summarize the origins, evidence base, and common components of best-practice models of dementia care, and we discuss barriers to their implementation. We conclude by describing two current efforts to implement such models on a broad scale, supported by the Center for Medicare and Medicaid Innovation. Taken together, these models seek to demonstrate improved dementia care quality and outcomes, accompanied by cost savings, in both community-based and institutional care settings.

Evaluation and management of the elderly patient presenting with cognitive complaints

Cognitive complaints are common in the geriatric population. Older adults should routinely be asked about any concerns about their memory or thinking, and any cognitive complaint from the patient or an informant should be evaluated rather than be attributed to aging. Several screening instruments are available to document objective impairments and guide further evaluation. Management goals for patients with cognitive impairment are focused on maintaining function and independence, providing caregiver support, and advance care planning. There are currently no treatments to effectively prevent or treat dementia. Increasing appreciation of the heterogeneity of Alzheimer disease may lead to novel treatment approaches.

Does an interdisciplinary network improve dementia care? Results from the IDemUck-study

BACKGROUND

Most persons with dementia live at home and are treated in the primary care. However, the ambulatory health care system in Germany contains a lot of "interface problems" and is not optimized for the future challenges. Innovative concepts like regional networks in dementia care exist on a project level and need to be tested for efficacy to encourage implementation. The goal of the study is the scientific evaluation of an already existing regional dementia network.

METHODS

Prospective randomized controlled trial of 235 community-living elderly with dementia and their family caregivers of network treatment (n=117) compared to usual care (n=118) in a predominantly rural region. The allocation to intervention or control group was based on network membership of their General Practitioner. Intervention patients received diagnostic evaluation and subsequent treatment according to network guidelines. Main outcome measures were the early contact with a neurologic or psychiatric specialist and dementia-specific medication as well as quality of life of the patients, and as secondary outcomes caregiver burden and caregiver health-related quality of life.

RESULTS

Network patients were more likely to receive antidementive drugs (50.5 % vs. 35.8 %; p=0.035) and had more often contact to a neurologist (18.6 % vs. 2.8 %; p<0.001). No group differences were found on patient's quality of life nor overall effects or treatment by time effects. Intervention caregivers reported no significant improvements in health related quality of life measured by SF-36 and EQ-5D.

CONCLUSION

The management of dementia patients in an interdisciplinary regional network solelyprovides measurable advantages with respect to the provision of dementia-specific medication and utilization of medical treatment i.e. referral rates to specialists. Further evaluation research is needed to identify relevant mechanismsof collaborative processes with respect to their impact on patient and caregiver related outcomes.

How family members manage risk around functional decline: the autonomy management process in households facing dementia

Most dementia research investigates the social context of declining ability through studies of decision-making around medical treatment and end-of-life care. This study seeks to fill an important gap in research about how family members manage the risks of functional decline at home. Drawing on three waves of in-depth interviewing in 2012-2014, it investigates how family members in US households manage decline in an affected individual's natural range of daily activities over time. The findings show that early on in the study period affected individuals were perceived to have awareness of their decline and routinely drew on family members for support. Support transformed when family members detected that the individual's deficit awareness had diminished, creating a corresponding increase in risk of self-harm around everyday activities. With a loss of confidence in the individual's ability to regulate his or her own activities to avoid these risks, family members employed unilateral practices to manage the individual's autonomy around his or her activity involvements. These practices typically involved various deceits and ruses to discourage elders from engaging in activities perceived as potentially dangerous. The study concludes by discussing the implications that the social context of interpretive work around awareness and risk plays an important role in how families perceive an elder's functional ability and manage his or her activity involvements.

The Home-Based Occupational Therapy Intervention in the Alzheimer's Disease Multiple Intervention Trial (ADMIT)

There is no way to prevent functional declines related to Alzheimer's Disease (AD). The use of occupational therapy (OT) has been shown to be successful in managing some aspects of AD. We added home-based OT to evidence-based best practice for AD with the aim of delaying functional decline in people with AD. OT was delivered in the home to a caregiver dyad including the person with AD and her/his caregiver. This paper describes the OT intervention for the AD Multiple Intervention Trial, a parallel randomized controlled trial. We include baseline data on the 180 caregiver dyads.

Web-based cognitive training: patient adherence and intensity of treatment in an outpatient memory clinic

Background

Cognitive training has been playing an increasing role in the treatment of patients with cognitive deficits. This type of intervention, namely its intensity, can be optimized by incorporating information technology-based systems.

Objective

The intent of the study was to determine the treatment intensity and patient adherence to home-based cognitive training strategies (Web-based cognitive training).

Methods

A cohort of 45 patients with neurologic and psychiatric diseases attending an outpatient memory clinic (average age 50.7 years, SD 17.0; average education 7.8 years, SD 4.9) was followed over 18 months. Participants were challenged to use a Web-based cognitive training system, “COGWEB”, on a daily basis, and fulfilled at least four weeks of training supervised remotely. Additionally, 11 patients attended face-to-face sessions.

Results

The average duration of continuous cognitive training was 18.8 weeks (SD 18.9). Each patient performed on average 363.5 minutes/week (SD 136.6). At 6-month follow-up, 82.8% complied with their treatment plan. The average proportion of complete weeks was 0.75 (SD 0.22). Patients with dementia trained more intensively (444.6 minutes/week), followed by patients with static brain lesion (414.5 minutes/week; P=.01). The group that held face-to-face sessions performed more training overall (481.4 vs 366.9 minutes/week), achieving a stronger expression and statistical significance in the last week of training (652.6 versus 354.9 minutes/week, P=.027).

Conclusions

Overall, the weekly training intensity was high. Patients with dementia and static lesions performed more cognitive training. Face-to-face sessions were associated with higher intensities. The combination of classical methods with information technology systems seems to ensure greater training intensity.