Behavioral disturbance in dementia

Delivering person-centred dementia care: Perceptions of radiography practitioners within diagnostic imaging and radiotherapy departments

INTRODUCTION

Despite abundant literature on the diagnosis of dementia, limited research has explored the lived experiences of radiography practitioners when providing care to people living with dementia in the department.

OBJECTIVES

This qualitative study explored the perceptions and compatibility of current professional guidance by both diagnostic imaging and radiotherapeutic radiography practitioners as well as the key stakeholders involved with developing the Society and College of Radiographers clinical practice guidelines for caring for people with dementia.

METHODS

This was a two-phase multi-method study. Fifteen diagnostic imaging and two therapeutic radiography practitioners from across the UK participated with online focus group discussions. Four key stakeholders involved with the development of the Society and College of Radiographers guidelines took part with individual semi-structured interviews. Data analysis included narrative and thematic analysis.

RESULTS

Participants from both phases identified enablers and barriers to providing person-centred dementia care. Three superordinate themes were identified linked to (1) Working with care partners, (2) Departmental environmental design, and (3) Communication and interprofessional infrastructure.

DISCUSSION

Many radiography practitioners still feel unprepared when caring for people living with dementia despite the clinical practice guidelines. Care partners were identified as having the potential to help alleviate some of the challenges radiographers faced. Participants were also aware of the impact of the departmental environment and recognised that poor way finding designs could lead to frustration. Radiography practitioners were not always aware that a patient was living with dementia prior to their attendance in the department making it difficult for practitioners to make appropriate accommodations such as additional time at appointments or the departmental environment. Our findings suggest there is a need for profession specific education and training for radiography practitioners to support the provision of person-centred dementia care. There is also a need to support the design of dementia friendly diagnostic imaging and radiotherapy departments.

Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being

BACKGROUND

The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal.

PURPOSE

To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49).

METHODOLOGY

Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics.

RESULTS

Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life.

CONCLUSIONS

Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being.

IMPLICATIONS

Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed.

Impact of agitation in long-term care residents with dementia in the United States

OBJECTIVES

To describe characteristics and compare clinical outcomes including falls, fractures, infections, and neuropsychiatric symptoms (NPS) among long-term care residents with dementia with and without agitation.

METHODS

A cross-sectional secondary analysis of administrative healthcare data was conducted whereby residents with dementia residing in a long-term care facility for ≥12 months were identified from the AnalytiCare LLC database (10/2010-06/2014) and were classified into mutually exclusive cohorts (Agitation Cohort or No-Agitation Cohort) based on available agitation-related symptoms. Entropy balancing was used to balance demographic and clinical characteristics between the two cohorts. The impact of agitation on clinical outcomes was compared between balanced cohorts using weighted logistic regression models.

RESULTS

The study included 6,265 long-term care residents with dementia among whom, 3,313 were included in the Agitation Cohort and 2,952 in the No-Agitation Cohort. Prior to balancing, residents in the Agitation Cohort had greater dementia-related cognitive impairment and clinical manifestations compared to the No-Agitation Cohort. After balancing, residents with and without agitation, respectively, received a median of five and four distinct types of medications (including antipsychotics). Further, compared to residents without agitation, those with agitation were significantly more likely to have a recorded fall (OR = 1.58), fracture (OR = 1.29), infection (OR = 1.18), and other NPS (OR = 2.11).

CONCLUSIONS

Agitation in long-term care residents with dementia was associated with numerically higher medication use and an increased likelihood of experiencing falls, fractures, infections, and additional NPS compared to residents without agitation, highlighting the unmet need for effective management of agitation symptoms in this population.

Treatment and Management of Sexual Disinhibition in Elderly Patients With Neurocognitive Disorders

Sexual disinhibition is uncommon but challenging symptom to address in elderly patients with neurocognitive disorders. Due to the lack of large-scale studies, there is no gold standard treatment for sexual disinhibition, and treatment is largely left up to the discretion of the provider based on the severity and onset of the patient's symptoms. A review was conducted to investigate the non-pharmacological and pharmacological interventions for treating this condition. Articles that discussed treatments were screened for the type of treatment and possible side effects of medication if applicable. Thorough patient history should be taken prior to starting any drug therapy to rule out possible behavioral changes due to an existing medication side effect, delirium, or past mental or sexual health history. Non-pharmacological treatment has been generally recommended as first-line therapy over pharmacological treatment. Distraction/diversion of the patient when inappropriate sexual behaviors occur was the most common non-pharmacological intervention. Antidepressants were generally recommended as the first line of pharmacological treatment after attempting all possible non-pharmacological interventions. Several other categories of interventions are discussed as well in addition to the ethical implications of treating a patient for this condition.

Is There a Characteristic Autonomic Response During Outbursts of Combative Behavior in Dementia Patients?

We sought to determine whether skin conductance level could warn of outbursts of combative behavior in dementia patients by using a wristband device. Two outbursts were captured and are reported here. Although no physiologic parameter measured by the wristband gave advance warning, there is a common pattern of parasympathetic withdrawal (increased heart rate) followed approximately 30 seconds later by sympathetic activation (increased skin conductance). In the literature, a similar pattern occurs in psychogenic non-epileptic seizures. We hypothesize that similar autonomic responses reflect similarities in pathophysiology and that physical activity may partially account for the time course of skin conductance.

Developing a virtual reality for people with dementia in nursing homes based on their psychological needs: a feasibility study

Background

The purpose of this study was (1) to develop a virtual reality (VR) intervention program based on the psychological needs of patients residing in nursing facilities in South Korea to alleviate their behavioral and psychological symptoms and (2) to confirm the possibility of utilizing VR in patients with dementia.

Methods

In the first phase, patients with dementia residing in nursing homes and experiencing behavioral and psychological symptoms were recruited. Surveys and questionnaires were used to identify activities that alleviated the behavioral and psychological symptoms of dementia (BPSD) among the patients. These activities were classified into five types of psychological needs. In the second phase, a fully immersive, interactive, easy-to-use VR platform was developed that reflected these psychological needs. Patients with dementia experienced the VR content. The researchers assessed the level of the participants’ immersion, preference, and interaction with the VR using a 5-point Likert scale.

Results

In the feasibility test, 10 nursing home residents were recruited. The mean immersion score was 4.93 ± 0.16 points, the mean preference score was 4.35 ± 0.41 points, and the mean interaction score was 3.84 ± 0.43 points using a 5-point Likert scale. Higher mean scores indicated a more positive outcome. Six of the 10 participants required assistance while using the VR. The mean VR experience duration was 10.00 ± 3.46 min.

Conclusions

The VR-based intervention program that was developed to reduce BPSD was feasible for the participants and provided them with a high degree of satisfaction and immersion. Furthermore, this study also confirmed the convenience and safety of the program. These findings support the potential use of VR-based BPSD intervention programs to treat patients with dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02125-w.

Caregivers' Experience at an Integrated Memory Care Clinic

The Integrated Memory Care Clinic is a patient-centered medical home led by advanced practice RNs (APRNs) who provide dementia care and primary care simultaneously and continuously. We explored the experiences of 12 informal caregivers of persons living with dementia during their first year at the Clinic. Data were analyzed via directed content analysis. Caregivers described the Clinic as "the only place you should go to for dementia [care]." Caregivers felt a sense of belonging to the Clinic, valued APRNs' competence and staff's dedication, and round-the-clock telephone access to APRNs. Caregivers also acknowledged that "we're all out here swimming on our own." They expressed their sense of being overwhelmed and needing more services and medical and non-medical resources, and more prognostic information on dementia. Although the Clinic is beneficial for caregivers, caregiving demands exceed the supply of services and resources at the Clinic. [Research in Gerontological Nursing, 14(2), 69-78.].

Behavioural intervention to reduce disruptive behaviours in adult day care centres users: A randomizsed clinical trial (PROCENDIAS study)

AIM

This study assesses the effect of an intervention to reduce the disruptive behaviours (DB) presented by care recipient users of adult day care centres (ADCC), thereby reducing caregiver overload. While ADCC offer beneficial respite for family caregivers, the DB that many care recipients show promote resistance to attending these centres, which can be a great burden on their family caregivers.

DESIGN

Randomized controlled clinical trial.

METHODS

The study was carried out with 130 family caregivers of people attending seven ADCC in the municipality of Salamanca (Spain), randomly distributed into intervention and control groups. The intervention was applied across eight sessions, one per week, in groups of 8-10 people where caregivers were trained in the Antecedent-Behavior-Consequence (ABC) model of functional behaviour analysis. The primary outcome was the reduction of DB measured with the Revised Memory and Behavior Problems Checklist (RMBPC).

RESULTS

An average reduction in the RMBPC of 4.34 points was obtained in the intervention group after applying the intervention (p < 0.01 (U de Mann-Whitney); Cohen d = 1.00); furthermore, differences were found in the Center for Epidemiologic Studies Depression Scale (CES-D) (U = -2.67; p = 0.008; Cohen d = 0.50) and in the Short Zarit Burden Interview (Short ZBI) (t = -4.10; p < 0.01; Cohen d = 0.98).

CONCLUSION

The results obtained suggest that the implementation of this intervention could reduce both the frequency of DB occurrence and the reaction of the caregiver to their appearance. Improvement was also noted in the results regarding overload and emotional state of the family caregiver.

IMPACT

To our knowledge, this is the first randomized clinical trial to show that an intervention based on the ABC model could reduce the frequency and reaction of DB of care recipients in ADCC increasing their quality of life, and improving the mental health and overload of their family caregivers.

Lessons learned from the statewide implementation of the Music & Memory program in nursing homes in Wisconsin in the USA

The movement of evidence-based interventions into institutional settings such as nursing homes is challenging. Among ecopsychosocial interventions to address behavioral problems of nursing home residents with dementia, Music and Memory, a popular intervention that provides individualized music listening, has shown potential to improve residents' quality of life. In Wisconsin in the USA, the Music and Memory program has been implemented in nursing home facilities statewide. In the present study, to examine facilitators and barriers related to implementation and sustainability of the Music and Memory program, all nursing homes in Wisconsin were invited to participate in a survey (online or mail). A total of 161 facilities participated, representing a response rate of 41%. Descriptive statistics and content analysis were conducted. Over 80% of responding facilities were providing the Music and Memory program, and 86% of those facilities planned to continue its use. The majority of respondents found Music and Memory to be beneficial to residents, but they also reported that the program was not equally effective for everyone and that it was time and labor intensive. Barriers to sustainability included lack of buy-in by direct care staff, use of technology, costs of equipment, inconsistency of volunteers, and families not supportive or helpful. Facilitators included support of facility personnel, family, and volunteers; observing positive effects of program; Music and Memory training provision and support; and accessibility of equipment. For the program to be successful, facilities must identify the residents most likely to benefit from it, realistically estimate its costs and required labor, and ensure staff buy-in.

Patient and caregiver outcomes at the integrated memory care clinic

The purpose of this longitudinal cohort study was to explore the outcomes of persons living with dementia (PLWD) and their caregivers during their first 9 months at the Integrated Memory Care Clinic (IMCC). IMCC advanced practice registered nurses provide dementia care and primary care simultaneously and continuously to PLWD until institutionalization. Changes were examined in caregivers' psychological well-being (perceived stress, depressive symptoms, caregiver burden, and anxiety) and health status and in PLWDs' quality of life and neuropsychiatric symptoms. Data were collected at baseline, then 3 and 6 months post-baseline. Forty-two caregivers completed all 3 assessments. Most variables remained unchanged. Statistically significant improvements in 5 sub-scales of the Neuropsychiatric Inventory were observed: caregivers' distress regarding their PLWDs' delusions and anxiety, and PLWDs' severity of delusions, depression, and total symptom severity. Further testing of the IMCC is required, including in quasi-experimental studies, to determine its efficacy.

Association of the US Food and Drug Administration Antipsychotic Drug Boxed Warning With Medication Use and Health Outcomes in Elderly Patients With Dementia

IMPORTANCE

Atypical antipsychotics (AAPs) are often used off-label to manage dementia-associated neuropsychiatric symptoms. In 2005, the US Food and Drug Administration (FDA) issued a boxed warning for the use of AAPs in elderly patients. The long-term association of this warning with health outcomes is unknown to date.

OBJECTIVE

To assess the long-term association of the 2005 FDA boxed warning on AAPs with psychiatric medication and opioid use, health events, and quality of life among elderly individuals with dementia.

DESIGN, SETTING, AND PARTICIPANTS

For this cross-sectional study, data were analyzed from the household component of the Medical Expenditure Panel Survey (MEPS), the National Ambulatory Medical Care Survey (NAMCS), and the National Hospital Ambulatory Medical Care Survey (NHAMCS) fielded between January 1, 1996, and December 31, 2014. This interrupted time-series analysis applied to 3-year moving means derived from the 1996-2014 MEPS, NAMCS, and NHAMCS. All survey respondents included in this analysis were 65 years or older and had dementia. Data analysis was performed from December 1, 2017, to March 15, 2018.

EXPOSURES

The 2005 FDA boxed warning on AAPs.

MAIN OUTCOMES AND MEASURES

Use of psychiatric medications and opioids, prevalence of cerebrovascular and cardiovascular events, prevalence of falls and/or fractures, 2-year mortality, and health-related quality of life assessed by the Medical Outcomes Study 12-Item Short-Form Health Survey scores.

RESULTS

A total of 2430 (MEPS) and 5490 (NAMCS and NHAMCS) respondents were identified, corresponding to weighted populations of 22 996 526 (MEPS) and 65 502 344 (NAMCS and NHAMCS) noninstitutionalized elderly individuals with dementia (mean [SD] age, 81.06 [1.13] years; 63.1% female). In the MEPS sample, compared with before 2005, AAP use (from an annual slope of 0.99 to -0.18 percentage points), cerebrovascular events (0.75 to -0.50 percentage points), and falls and/or fractures (-1.72 to -0.40 percentage points) decreased and opioid use (0.04 to 1.29 percentage points), antiepileptic use (-0.42 to 1.21 percentage points), cardiovascular events (-0.13 to 1.30 percentage points), and 2-year mortality risk (-0.68 to 0.18 percentage points) increased. Health-related quality of life remained relatively unchanged. The NAMCS and NHAMCS sample yielded similar findings.

CONCLUSIONS AND RELEVANCE

These data suggest that the 2005 FDA boxed warning was associated with some unintended negative patient outcomes.

When Older People Are Violent or Abusive Toward Their Family Caregiver: A Review of Mixed-Methods Research

What happens when family caregivers experience violence and abuse from the older person for whom they care? Although this issue has received little global attention, it is relevant to researchers, practitioners, and policy makers working across the intersecting fields of older age care and medicine, adult protection and safeguarding, and domestic and intimate partner violence. To date, these fields have generated diverse explanations of violence and abuse in older age illness and how best to respond to it. This article reports the findings of a systematic literature review of 18 quantitative, qualitative, and mixed-methods studies that investigated violent and abusive behavior by older people toward their family caregivers. The review identified three central themes in the literature: (1) There are inconsistent definitions and measurements used in research about harmful, violent, and abusive behavior toward family caregivers. (2) Violent and abusive behavior toward caregivers is a sensitive and hidden topic that poses practical and methodological challenges for researchers. (3) There is some evidence to suggest that people who were violent and abusive in their earlier life-or who had a poor relationship with their family member in the past-are more likely to continue to experience violence and abusive behavior in later life. There were two central ways in which violence and abuse were conceptualized and investigated: as a "symptom of illness" or as an "act of abuse" and we present a visual map of the relationship between these two conceptualizations drawn from our analysis of the literature. We conclude by discussing the implications of the findings and recommend future directions for practice, research, and policy to support affected families.

Institutionalization risk and costs associated with agitation in Alzheimer's disease

Introduction

Agitation in individuals with Alzheimer's disease (AD) may predict institutionalization. This study assessed the incremental risk and costs associated with agitation in individuals with AD.

Methods

A retrospective analysis of the National Alzheimer's Coordinating Center Uniform Data Set (June 2005–February 2018) was conducted. Incremental risk of institutionalization associated with agitation was estimated and used with the number of institutionalized individuals with AD and agitation and costs of living by residential setting in the United States (literature-based), to estimate incremental institutionalization costs.

Results

The analysis included 11,348 individuals with AD: 6603 (58.2%) with and 4745 (41.8%) without agitation. Compared with individuals without agitation, those with agitation were 20% more likely to be institutionalized (odds ratio = 1.20; 95% CI = 1.08–1.33). Total incremental cost of institutionalization associated with agitation was $4.3 billion ($50,588/individual).

Discussion

Agitation is associated with a higher risk of institutionalization among patients with AD, which translates into a substantial economic burden.

•

Agitation in Alzheimer's disease portends higher risk of institutionalization.

•

Higher institutionalization risk translates into a substantial economic burden.

•

Agitation-related institutionalization cost was ∼$4.3 billion in the United States.

Use of ECT in Major Vascular Neurocognitive Disorder with Treatment-Resistant Behavioral Disturbance following an Acute Stroke in a Young Patient

The following case describes the utilization of bitemporal ECT as a treatment of last resort in a 47-year-old woman with profoundly treatment-resistant behavioral disturbance poststroke. The use of ECT led to improvement in symptoms sufficient for discharge from an inpatient psychiatric unit to the nursing home. Neuropsychiatric sequelae of stroke include poststroke depression, anxiety, mania, psychosis, apathy, pathological laughter and crying, catastrophic reaction, and mild and major vascular neurocognitive disorders. Behavioral disturbance is common and may pose diagnostic and therapeutic difficulty in the poststroke patient. In most cases, first-line treatment includes pharmacologic intervention tailored to the most likely underlying syndrome. Frequent use of sedating medications is a more drastic option when behaviors prove recalcitrant to first-line approaches and markedly affect quality of life and patient safety. ECT is generally safe, is well tolerated, and may be effective in improving symptoms in treatment-resistant behavioral disturbance secondary to stroke with major neurocognitive impairment, as suggested in this case.

Delirium and Antipsychotic Medications at Hospital Intake: Screening to Decrease Likelihood of Aggression in Inpatient Settings Among Unknown Patients With Dementia

For individuals with dementia, disorientation and both external and internal stimuli may trigger behaviors that are difficult to manage or dangerous to health-care providers. Identification of correlational risk factors to aggressive behavior in patients who are unknown to the hospital can allow providers to adapt patient care quickly. Records for patients aged 60+ who spent at least 24 hours at the hospital other than in the psychiatric unit were used (N = 14 080). The first 4000 records and every 10th person who met criteria (N = 5008) were searched for documentation of dementia (n = 505). Logistic regressions and χ2 tests were used to examine relationships between variables. Recognition of delirium (P = .014, Exp(B) = 2.53), coupled with an existing prescription for antipsychotic medication at intake (P < .001, Exp(B) < 4.37), may be a reliable means of screening for risk and intervening at the earliest possible contact, improving quality of care and safety in acute care for individuals with dementia.

Treatment patterns and burden of behavioral disturbances in patients with dementia in the United States: a claims database analysis

Background

Although patients with dementia frequently experience neuropsychological symptoms (NPS) such as agitation, which profoundly impacts patients, caregivers, and the healthcare system, few studies have evaluated the associated burden of agitation or agitation-related symptoms in dementia.

Methods

This retrospective analysis of claims data from the Truven Health MarketScan® database (2012–2015) compared clinical characteristics, treatment patterns, healthcare resource utilization, and costs among patients with dementia with behavioral disturbances (BD) versus patients with dementia without BD. Existing BD diagnosis codes 294.11 or 294.21 were used as a means to identify patients with agitation/agitation-related symptoms.

Results

From a starting sample of 6.4 million beneficiaries, 103,402 patients with dementia were identified, of whom 16,440 (16%) had BD during an average of 17 months of follow-up. Patients with BD had significantly more medical and psychiatric comorbidities and greater comedication use (i.e., antidementia drugs, antidepressants, and antipsychotics; all values, P < .0001) compared with patients without BD. A significantly greater number of hospitalizations, hospital days, outpatient hospital/clinic visits, number of skilled nursing visits, and number of patients with hospice visit were reported during follow-up in patients with BD compared with patients without BD (all values, P <  0.0001). Costs were also significantly higher among patients with BD versus those patients without BD ($42,284 vs. $32,640, respectively; P <  0.0001).

Conclusions

Patients with dementia with BD had a higher prevalence of comorbidities, greater use of comedications, and greater healthcare utilization and costs than patients with dementia without BD.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1260-3) contains supplementary material, which is available to authorized users.

Resident-Level Factors Associated with Hospitalization Rates for Newly Admitted Long-Term Care Residents in Canada: A Retrospective Cohort Study

Chez les résidents en soins de longue durée (SLD), l’hospitalisation peut amener des complications telles que le déclin fonctionnel. L’objectif de notre étude était d’examiner l’association entre les données démographiques et de santé et le taux d’hospitalisation des résidents nouvellement admis en SLD. Nous avons mené une étude de cohorte rétrospective incluant tous les centres de SLD de six provinces et d’un territoire du Canada, à l’aide des données de la RAI-MDS 2.0 et de la Discharge Abstract Database. Nous avons inclus les résidents nouvellement admis ayant eu une évaluation entre le 1er janvier et le 31 décembre 2013 (n = 37 998). Les résidents de sexe masculin avec une santé plus instable et une déficience fonctionnelle de modérée à grave présentaient des taux d’hospitalisation plus élevés, tandis que les résidents avec une déficience cognitive de modérée à grave avaient des taux moindres. Les résultats de notre étude pourraient contribuer à l’identification des résidents nouvellement admis qui seraient plus à risque d’hospitalisation et à l’élaboration de stratégies préventives plus ciblées, incluant la réadaptation, la planification préalable de soins, les soins palliatifs et les services gériatriques spécialisés.

Psychometric Properties of the Spanish Version of the Caregiver Burden Inventory

Although the Caregiver Burden Inventory (CBI) is the most widely used multidimensional burden instrument for assessing perceived burden of caregivers, there is no data on its psychometric properties in Spanish, nor on caregivers of dependent persons with various diseases. The objective of this study was to translate the CBI into Spanish and validate it in caregivers of dependent persons with various diseases. Trained evaluators administered the CBI and assessed emotional distress and probable mental disorder in 201 caregivers (87.1% women, mean age 56.2 years). The internal consistency of the CBI was 0.89 (0.74–0.83 among the subscales). There was a significant correlation of emotional distress with both the total burden and each subscale (p < 0.001 in all cases). A total score of 39 and scores of 16, 9, 8, 4, and 2 in burden per time dedicated to care, personal life burden, physical burden, social burden, and emotional burden were suitable cut-off points to discriminate caregivers with probable mental disorder (sensitivity = 63.0%–75.6%, specificity = 63.4%–74.4%). To achieve a greater goodness of fit, the model was re-specified, resulting in a shortened (15-item) instrument. The internal consistency reliability coefficients of the 15-item CBI were satisfactory (Cronbach α = 0.83; 0.77–0.86 among the subscales). Within the 15-item CBI, emotional distress was significantly correlated with the total burden, personal life burden, physical burden, social burden (p < 0.001 in all those cases), and emotional burden (p = 0.001). A total score of 25 and scores of 12, 5, 5, 3, and 1, respectively, in the subscales were identified as cut-off points to discriminate caregivers with probable mental disorder (sensitivity = 46.2%–70.6%, specificity = 43.9%–79.3%). Therefore, the 15-item CBI validly measured caregiver burden with better fit and more parsimoniously than the original CBI.

Positive Interactive Engagement (PIE): A pilot qualitative case study evaluation of a person-centred dementia care programme based on Montessori principles

Altered behaviour associated with dementia can present a number of challenges in the provision of care within both community and residential aged care settings. This paper presents a qualitative case study investigation of the implementation of the Positive Interactive Engagement programme within a residential aged care setting. The Positive Interactive Engagement programme incorporates non-pharmacological sensory techniques that have been informed by a person-centred, Montessori approach. Face-to-face semi-structured interviews with workers at a residential aged care facility in South Australia yielded seven case studies. Data were thematically analysed both within and between cases. Our data indicate the programme demonstrates underlying Montessori principles and supports participant behaviour change, with a noted reduction in ‘disruptive’ behaviours and increased social connection amongst participants. Programme staff report increased job satisfaction. The Positive Interactive Engagement programme offers a model that demonstrates encouraging outcomes, and further research would be useful in ascertaining whether these outcomes translate to quantifiable improvements in the quality of life for people with dementia in a residential aged care setting.

Testing Tele-Savvy: Protocol for a randomized controlled trial

Many informal caregivers of persons with dementia suffer adverse health consequences. Although established psychoeducation programs are known to benefit caregivers, attending in-person programs is challenging for them. To address this challenge, the Savvy Caregiver Program, an evidence-based psychoeducation program with demonstrated effectiveness for caregiving and disease-related outcomes, was transformed into an on-line program, Tele-Savvy. This article describes the rationale for and design of a prospective longitudinal randomized controlled trial (targeted N = 215), currently underway. The trial aims to establish Tele-Savvy's efficacy in (i) reducing the negative effects of caregiving on caregivers; (ii) promoting care recipients' quality of life; (iii) improving caregiver mastery; and to explore (iv) Tele-Savvy's efficacy among caregivers of different races/ethnicities. The mediating role of mastery will be assessed. Participants are randomized to the active condition (immediate Tele-Savvy participation), attention control, or usual care. Participants in the two latter conditions will complete Tele-Savvy 6 months post-baseline. Multilevel mixed effects models will be used to examine changes in outcomes and to model group by time (months since baseline) interactions. The exploratory aim will be addressed using analysis of covariance and qualitative analysis. This trial's results may be used by healthcare and community organizations to implement Tele-Savvy in dementia care, increasing caregivers' access to this evidence-based intervention.

Rest-activity rhythms in small scale homelike care and traditional care for residents with dementia

Background

An enriched environment for residents with dementia may have a positive effect on the rest-activity rhythm. A small scaled homelike special care unit might be such an enriched environment. The present study shows whether the rest-activity rhythm of residents with moderate to severe dementia responds positively to a transfer from a regular Special Care Unit (SCU) to a small scaled homelike SCU.

Methods

Initially, a group of 145 residents living in a regular SCU participated. Out of this group, 77 residents moved to a small scaled homelike SCU. This group was compared to the group of 68 residents that remained at the regular SCU. Rest-activity rhythm was assessed by means of actigraphy and observation scales before and after relocation.

Results

No significant main effects nor significant interaction effects in intradaily and interdaily activity were found for the data of 38 residents in the small scaled homelike SCU and 20 residents of the regular SCU. The effect sizes, however, ranged from small to large.

Conclusions

Considering the effect sizes, a new study with a larger number of participants is necessary before firm conclusions can be drawn.

Trial registration

Current Controlled Trials ISRCTN11151241. registration date: 21–06-2017. Retrospectively registered.

The association of eating performance and environmental stimulation among older adults with dementia in nursing homes: A secondary analysis

BACKGROUND

Nursing home residents with dementia experience increased risk for compromised eating performance due to intrapersonal, interpersonal, and environmental factors. Environmental stimulation is physical, social, and/or sensory stimulation present in the environment that can potentially trigger individuals' emotion or motivate physical reactions. Beyond the personal factors, there is a lack of evidence on how environmental stimulation influences individuals' eating performance at mealtimes.

OBJECTIVES

This study examined the association between environmental stimulation and eating performance among nursing home residents with dementia.

DESIGN

This study was a secondary analysis using baseline videos selected from a communication intervention study, where videos were recorded to capture staff-resident interactions during care activities for nursing home residents with dementia. Videos were included in this study only if residents demonstrated eating activities at mealtimes.

SAMPLE AND SETTING

A total of 36 videos were selected (mean length=4min). The sample included 15 residents with dementia (mean age=86), and 19 certified nursing assistants (mean age=36) in 8 nursing homes.

METHODS

The dependent variable was eating performance as measured by the Level of Eating Independence scale (range: 15-36, with higher scores indicating better eating performance). The independent variables were characteristics of environmental stimulation measured by the Person-Environment Apathy Rating-Environment subscale (stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback). Each characteristic was rated on a 1-4 scale with higher scores indicating more desirable environmental stimulation. Multilevel models were used to examine the association between eating performance and environmental stimulation, adjusting for resident characteristics (i.e., age, gender, dementia stage, function, comorbidity, psychoactive medication use) and nesting effects of residents and staff.

RESULTS

Resident participants demonstrated moderate levels of eating performance (M=27.08, SD=5.16). Eating performance was significantly lower among older residents, those with more advanced dementia, and higher comorbidity. After controlling for resident characteristics, eating performance was significantly associated with stimulation specificity (how the stimulation is delivered and tailored to the resident), and was not associated with other environmental stimulation characteristics. For each 1 point increase in stimulation specificity, eating performance increased by 8.78 points (95% CI=0.59, 16.97).

CONCLUSIONS

Environmental stimulation that is personally tailored to a resident' needs and preferences and directly offered to a resident contributed to better eating performance among residents with dementia. The findings will direct future development and implementation of person-directed mealtime care programs and dining environment arrangements for residents with dementia in nursing homes.

Buspirone for the treatment of dementia with behavioral disturbance

Behavioral disturbances are common but serious symptoms in patients with dementia. Currently, there are no FDA approved drugs for this purpose. There have been case reports and small case series of the use of buspirone. In this retrospective study, we review 179 patients prescribed buspirone for treatment of behavioral disturbance in dementia to better characterize the efficacy and potential side effects. All patients prescribed buspirone for behavioral disturbance due to dementia from a geropsychiatric outreach program were reviewed. Data was collected and analyzed using SPSS. One hundred-seventy-nine patients met criteria for the study with a mean age of 83.8 + 7. Alzheimer's dementia was the most common dementia (n = 61; 34.1%) followed by mixed dementia (n = 50, 27.9%) then vascular type (n = 31; 17.3%). Behavioral disturbances were mainly verbal aggression (n = 125; 69.8%), and physical aggression (n = 116; 64.8%). Using the Clinical Global Impression scale, 68.6% of patients responded to buspirone, with 41.8% being moderately to markedly improved. The mean dose of buspirone was 25.7 mg ± 12.50. Buspirone appears to be effective in treating behavioral disturbances in dementia. Future prospective and double blinded studies are needed.

Prevalence, Patterns and Predictors of Psychotropic Polypharmacy Among Elderly Individuals with Parkinson's Disease In Long Term Care Settings In The United States

BACKGROUND

Elderly individuals with Parkinson's disease (PD) generally suffer from more than one psychiatric comorbidity, which necessitates the use of concurrent psychotropic medications. To the best of the author's knowledge there are no nationally representative estimates of psychotropic polypharmacy among elderly individuals with PD in the United States (US).

OBJECTIVE

Therefore, the primary objective of this study was to examine the prevalence, patterns and predictors of psychotropic polypharmacy among elderly individuals with PD in the (US).

METHODS

A retrospective, cross-sectional study design with 2004 National Nursing Home Survey (NNHS) and 2007 National Home and Hospice Care Survey (NHHCS) data was used. The analytic sample included elderly (age ≥65 years) individuals with PD. Antidepressants, antipsychotics, sedative/hypnotics, and anti-anxiety medications constituted the psychotropic medication classes. Concurrent use of two or more psychotropic medications was classified as psychotropic polypharmacy.

RESULTS

Approximately 93,648 and 37,439 elderly individuals with PD resided in nursing homes and home health settings respectively. Among elderly nursing home residents with PD, the nationally representative prevalence of psychotropic polypharmacy was 26.28%, whereas, it was 21.36% in the home health setting. Use of antidepressant medications constituted the majority of the psychotropic medication use among both nursing home (48.91%) and home health (40.98%) residents with PD. Multiple logistic regression analyses revealed that specific comorbidities were significantly associated with psychotropic polypharmacy among elderly nursing home residents with PD.

CONCLUSIONS

These findings underscore the importance of evidence-based prescribing when psychotropic medications are used in elderly individuals with PD to reduce unnecessary polypharmacy.

Intranasal Piperine-Loaded Chitosan Nanoparticles as Brain-Targeted Therapy in Alzheimer's Disease: Optimization, Biological Efficacy, and Potential Toxicity

Piperine (PIP) is a phytopharmaceutical with reported neuroprotective potential in Alzheimer's disease (AD). Oral PIP delivery suffers from its hydrophobicity and pre-systemic metabolism. In this article, mono-disperse intranasal chitosan nanoparticles (CS-NPs) were elaborated for brain targeting of PIP. Formula optimization was based on particle size (PS), zeta potential (ZP), polydispersity index (PDI), % entrapment efficiency (% EE), release studies, and transmission electron microscopy. AD was induced in 48 male Wistar rats on which full behavioral and biochemical testing was conducted. Brain toxicity was assessed based on Caspase-3 assay for apoptosis and tumor necrosis factor for inflammation. Spherical NPs with optimum % EE (81.70), PS (248.50nm), PDI (0.24), and ZP (+56.30mV) were elaborated. PIP-NPs could significantly improve cognitive functions as efficient as standard drug (donpezil injection) with additional advantages of dual mechanism (Ach esterase inhibition and antioxidant effect). CS-NPs could significantly alleviate PIP nasal irritation and showed no brain toxicity. This work was the first to report additional mechanism of PIP in AD via anti-apoptosis and anti-inflammatory effects. To conclude, mucoadhesive CS-NPs were successfully tailored for effective, safe, and non-invasive PIP delivery with 20-folds decrease in oral dose, opening a gate for a future with lower AD morbidity. © 2015 Wiley Periodicals, Inc. and the American Pharmacists Association J Pharm Sci 104:3544-3556, 2015.

The Role of Sleep and Sleep Disorders in the Development, Diagnosis, and Management of Neurocognitive Disorders

It is becoming increasingly apparent that sleep plays an important role in the maintenance, disease prevention, repair, and restoration of both mind and body. The sleep and wake cycles are controlled by the pacemaker activity of the superchiasmic nucleus in the hypothalamus but can be disrupted by diseases of the nervous system causing disordered sleep. A lack of sleep has been associated with an increase in all-cause mortality. Likewise, sleep disturbances and sleep disorders may disrupt neuronal pathways and have an impact on neurological diseases. Sleep deprivation studies in normal subjects demonstrate that a lack of sleep can cause attention and working memory impairment. Moreover, untreated sleep disturbances and sleep disorders such as obstructive sleep apnoe (OSA) can also lead to cognitive impairment. Poor sleep and sleep disorders may present a significant risk factor for the development of dementia. In this review, the underlying mechanisms and the role of sleep and sleep disorders in the development of neurocognitive disorders [dementia and mild cognitive impairment (MCI)] and how the presence of sleep disorders could direct the process of diagnosis and management of neurocognitive disorders will be discussed.

Optimizing Eating Performance for Long-Term Care Residents With Dementia: Testing the Impact of Function-Focused Care for Cognitively Impaired

OBJECTIVES

The objective of this study was to evaluate the impact of a well-developed theory-based function-focused care for cognitively impaired (FFC-CI) intervention on eating performance among long-term care (LTC) residents with moderate-to-severe cognitive impairment.

DESIGN

A secondary analysis of longitudinal data from 2 cluster-randomized controlled trials that originally tested the impact of FFC-CI on all function and physical activities.

PARTICIPANTS AND SETTING

Participants were 199 residents with moderate-to-severe cognitive impairment from 4 nursing homes and 4 assisted living facilities.

MEASUREMENTS

Data at baseline, and 3 and 6 months were used. Resident outcome data used in this analysis included eating performance conceptualized using the single self-care "feeding" item in the Barthel Index, cognitive function by Mini-Mental State Examination, sitting balance conceptualized using the single "chair sit-sitting balance" item in the Tinetti Gait and Balance scale, physical capability by Physical Capability Scale, depression by Cornell Scale for Depression in Dementia, and agitation by Cohen-Mansfield Agitation Inventory (short form).

RESULTS

At baseline, almost one-third (32.2%) of the 199 residents needed help with eating. There was no significant change with regard to eating performance over time in both groups, and no significant treatment by time difference between groups in eating performance (P = .195).

CONCLUSION

Current findings support a need to revise the FFC-CI to better address eating performance. Future work may benefit from a stronger focus on eating performance rather than the more commonly addressed functional tasks, such as bathing, dressing, and ambulation. In addition, the inclusion of a more heterogeneous group of LTC residents with regard to eating performance is needed to test the impact of the revised approach on eating performance.

Review of antidepressants in the treatment of behavioral and psychiatric symptoms in dementia (BPSD)

Behavioral disturbances are commonplace among patients with dementia. Management of these symptoms has proved difficult.1,2 Currently, there are no FDA approved pharmacologic treatments for the treatment of BPSD.3 Traditionally, atypical antipsychotics have been used to treat behavioral disturbances despite modest efficacy and undesirable adverse effects.34,5 Because of the increase in mortality, there is a continued push to reduce antipsychotic utilization in this population.9,10 Thus, many clinicians are using alternative agents such as antidepressants and mood stabilizers to help treat BPSD, while avoiding using antipsychotics. The goal of this review is to review, analyze, and discuss the current literature available on the use of antidepressants to treat BPSD.

Approach to insomnia in patients with dementia

Insomnia occurs in one-fourth to one-third of patients with dementia, and can lead to patient and caretaker distress and early institutionalization. An array of effects from the disease, medication, behaviors, and mood issues may play a role in influencing sleep. This perplexing issue can be handled effectively with appropriate evaluation and understanding of basic sleep-wake physiology. For most patients, appropriate timing of cues, modifying behavior, and optimizing medications can improve the patient's and caregiver's quality of life. In this article, we review signs that may help the clinician recognize insomnia early and approach the issue in a logical manner.

Optimizing function and physical activity among nursing home residents with dementia: testing the impact of function-focused care

PURPOSE OF THE STUDY

The purpose of this study was to test the impact of Function-Focused Care for the Cognitively Impaired Intervention on nursing home residents with dementia and the nursing assistants who care for them.

DESIGN AND METHODS

This was a cluster-randomized controlled trial using repeated measures. A total of 103 cognitively impaired residents and 77 nursing assistants were recruited from four nursing homes. For residents, outcome measures included function, physical activity (survey and actigraphy), mood, behavior, and adverse events (falls and hospitalization). Main outcome measures for nursing assistants included knowledge, beliefs, and performance of function focused care.

RESULTS

There were significant improvements in the amount and intensity of physical activity (by survey and actigraphy) and physical function in the treatment group. In addition, there was a significant decrease in the number of residents who fell during the treatment period with those in the treatment sites having fewer falls (28% vs. 50% in the control group). Nursing assistants were also observed to be providing a greater percentage of function focused care during resident care interactions in the treatment group at 6 months following the completion of baseline measures.

IMPLICATIONS

This study provides some evidence that nursing home residents with severe cognitive impairment can safely and successfully be engaged in physical and functional activities.

The association between caregiver distress and individual neuropsychiatric symptoms of dementia

Neuropsychiatric symptoms (NPS) of dementia constitute one of the most related factors to caregiver burden and patients' early institutionalization. Few studies in Brazil have examined which symptoms are associated with higher levels of caregiver distress.

Cognitive stimulation in patients with dementia: randomized controlled trial

BACKGROUND/AIMS

This study explores the effective outcomes of a structured cognitive stimulation treatment to improve cognition and behavioral symptoms in people with dementia (PWDs), using a randomized controlled clinical trial.

METHODS

THIRTY PWDS WERE DIVIDED INTO THREE GROUPS: experimental (treated with cognitive stimulation), placebo (treated with occupational therapy), and control (continuing with the usual activities of the nursing home). Assessment, at baseline and after a period of 8 weeks, was performed using the Clinical Dementia Rating Scale, activities of daily living, Mini-Mental State Examination, Esame Neuropsicologico Breve 2, Geriatric Depression Scale and Behavioral Pathology in Alzheimer's Disease Scale.

RESULTS

Only the experimental group improved its performance in cognitive tests (p < 0.05) and showed a significant decrease in behavioral symptoms (p < 0.01) after the treatment.

CONCLUSIONS

The results suggest that a cognitive stimulation treatment for PWDs would improve not only their cognition, but also behavioral symptoms.

A literature-based intervention for older people living with dementia

Background:

While several studies have explored the impact of literature and reading on mental health, there has been relatively little work done on how a literature-based intervention might impact on the behaviours of those living with dementia. The present report addresses the effect that a specific literature-based intervention – Get into Reading, designed and practised by national charity The Reader Organisation – might have on the health and well-being of people living with dementia.

Aims:

This present study arises out of a service evaluation that specifically assessed to what extent the shared-reading intervention impacted upon behaviours symptomatic of dementia. Its aims were: (1) to understand the influence that reading has on older adults with dementia in different health-care environments; (2) to identify staff perceptions of the influence that engagement in a reading group has on older adults living with dementia; and (3) to investigate any changes in dementia symptoms of older adults participating in a reading group.

Methods:

The study employed a mixed-method design conducted within three health-care environments: three care homes, two hospital wards and one day centre. The Neuropsychiatric Inventory Questionnaire (NPI-Q) assessed staff views of any changes in dementia symptom severity for participants in reading groups conducted in the care homes. Semi-structured qualitative interviews were then conducted with staff who attended the reading groups and/or had extensive knowledge of service users involved in all of the health-care settings. Responses to questions were recorded verbatim and then subject to thematic analysis.

Results:

61 service users and 20 staff members took part in the overall project. The NPI-Q results indicate that symptom scores were lower during the reading group period than at baseline. These findings were supported by the qualitative interviews, which suggested that three themes were perceived to be important to effective engagement with the reading groups: (1) the components of the reading group intervention; (2) enjoyment, authenticity, meaningfulness and renewed sense of personal identity; and (3) enhancement of listening, memory and attention.

Conclusions:

In light of quantifiable data of limited but indicative status, together with strongly corroborative qualitative evidence, engagement in reading-group activity appeared to produce a significant reduction in dementia symptom severity. Staff interviews indicated the contribution of reading groups to well-being.