Self-maintenance therapy in Alzheimer's disease

Wisdom Once Gained Is Not Easily Lost: Implicit Theories About Wisdom and Age-Related Cognitive Declines

Background and Objectives

Most people agree that cognitive capabilities are an integral component of wisdom and its development. However, a question that has received less attention is whether people view maintaining cognitive capabilities as a necessary prerequisite for maintaining wisdom.

Research Design and Methods

This study used a mixed-methods approach to evaluate people's views about the relationship between age-related cognitive declines, Alzheimer's disease (AD), and wisdom. Our final sample of 1,519 adults ranged in age from 18 to 86.

Results

The majority of participants stated that wisdom could be present even in people with significant age-related cognitive declines or with AD. In the qualitative responses, common justifications for this were (a) that even people with severe AD can still exhibit wise behaviors during lucid moments, (b) that wisdom is an immutable characteristic that is impossible to lose, and (c) that wisdom maintenance and cognitive capability maintenance are separate constructs.

Discussion and Implications

Although prior research has examined implicit theories about the role of cognition in the development of wisdom, this is the first study to examine implicit theories about whether cognitive declines lead to wisdom declines. The results suggest that most people hold essentialist beliefs about wisdom, viewing it as a fixed and unchangeable trait rather than as a malleable skill.

Discontinuity in the Subjective Experience of Self Among People with Mild-To-Moderate Dementia Is Associated with Poorer Psychological Health: Findings from the IDEAL Cohort

BACKGROUND

The onset and progression of dementia can result in changes in the subjective experience of self, impacting on psychological health.

OBJECTIVE

We aimed to explore the extent to which people with mild-to-moderate dementia experience discontinuity in the subjective experience of self, and the factors associated with this experience for people with dementia and their family caregivers.

METHODS

We used data from the baseline assessment of the IDEAL cohort. Discontinuity in the subjective experience of self was assessed by asking participants about their agreement with the statement 'I feel I am the same person that I have always been'. Participants were divided into those who did and did not experience discontinuity, and the two groups were compared in terms of demographic and disease-related characteristics, psychological well-being, measures of 'living well', and caregiver stress.

RESULTS

Responses to the continuity question were available for 1,465 participants with dementia, of whom 312 (21%) reported experiencing discontinuity. The discontinuity group experienced significantly poorer psychological well-being and had significantly lower scores on measures of 'living well'. There was no clear association with demographic or disease-related characteristics, but some indication of increased caregiver stress.

CONCLUSION

A significant proportion of people with mild-to-moderate dementia describe experiencing discontinuity in the subjective sense of self, and this is associated with poorer psychological health and reduced ability to 'live well' with the condition. Sensitively asking individuals with dementia about the subjective experience of self may offer a simple means of identifying individuals who are at increased risk of poor well-being.

Comparison of psychosocial and medical characteristics of patients with dementia and their primary informal caregivers between inpatient and day clinic treatment

Background

Caregiver burden is one of the most common reasons for hospitalization of patients with dementia. However, changes of location are not recommended for patients with dementia and associated with negative outcomes for patients with dementia. As there is yet a lack of outpatient treatment options, this study explores psychiatric day clinic treatment as option for patients with dementia by comparing characteristics of voluntarily treated patients with dementia and their respective informal caregivers between an inpatient and day clinic setting.

Methods

A total of 92 patients with dementia (56 inpatient, 36 day clinic) and their informal caregiver provided information on psychosocial and clinical characteristics (Mini-Mental-Status-Test, Neuropsychiatric Inventory, Bayer Activities of Daily Living, Barthel Index, Geriatric Depression Scale-30, Beck’s Depression Inventory-II, caregiver burden, Short Form Health Survey-36) at the beginning of treatment and at follow-up (n = 48 patient caregiver dyads) six months after discharge.

Results

Patients with dementia did not differ in disease severity, neuropsychiatric symptoms, and depression depending on treatment setting. However, the higher the Bayer activities of daily living score, the more likely treatment in day clinic was. Caregivers from patients with dementia in the inpatient setting were younger and reported more financial burden, whereas caregivers from patients with dementia in the day clinic reported lower physical health and more burden due to practical caring responsibilities. Longitudinal data indicated no differences in characteristics of patients with dementia and caregivers depending on treatment setting, despite caregivers from patients in the day clinic reporting more depressive symptoms after six months.

Conclusion

Day clinic treatment for voluntarily treated patients with dementia might be an alternative to inpatient settings. Patients with dementia do not substantially differ depending on treatment setting, rather characteristics of the caregivers were associated with placement in inpatient or day clinic setting. The needs of caregivers deserve special attention when considering treatment for patients with dementia.

Perceptions of change over time in early-stage Alzheimer's disease

Emerging models of subjective experience, awareness and coping in early-stage dementia may usefully be enhanced by incorporating a temporal perspective. As an initial step in this direction, we undertook a prospective one-year follow-up of participants with a diagnosis of early-stage Alzheimer's disease whose accounts had contributed to the development of Clare's phenomenological model of awareness incorporating the continuum model of coping in early-stage dementia. All 12 participants from the original study completed a follow-up interview one year later. Interpretative phenomenological analysis was used to identify emergent themes. All participants continued to demonstrate some awareness of difficulties with memory, but individuals varied in their evaluations of the extent and implications of these changes, with the majority tending towards more normalizing explanations. Many were nevertheless making practical adjustments to their activities, and the need to renegotiate relationships was a prominent issue. Subsequently, the data were examined for evidence of the themes identified in the original study, the initial model was reapplied, and changes in individual coping style over time were explored through case study analysis. The range of processes and coping styles observed across participants 12 months earlier was still apparent, with some indication of increased polarization between self-maintaining and self-adjusting styles of coping. A small number of participants showed significant changes in coping style, with changes occurring in both directions. The findings suggest that expression of awareness interacts with coping style, illustrating the need to consider both factors in combination in order to better understand individual expressions of awareness of change.

Cognitive behavioural treatment for mild Alzheimer's patients and their caregivers (CBTAC): study protocol for a randomized controlled trial

Background

About 90 % of all persons with mild Alzheimer’s disease experience neuropsychiatric symptoms, most frequently apathy, depression, anxiety and irritability. These symptoms are associated with greater morbidity, a reduced quality of life for the patient, an increased burden and depression for the caregiver, and higher costs of care and nursing home placement. Psychosocial interventions based on behaviour therapy represent the most efficacious treatment of neuropsychiatric symptoms. However, there is no study, to our knowledge, that has evaluated a multicomponent treatment programme based on comprehensive, cognitive behavioural therapy (CBT). This randomized controlled trial aims to evaluate a CBT-based treatment programme consisting of 8 modules and 25 sessions.

Methods/design

Fifty patients with mild Alzheimer’s disease alone or with mild mixed dementia (Alzheimer’s disease and vascular dementia) who have any neuropsychiatric symptom will be included. A caregiver must be available. The patients and their caregivers will be randomized to either the CBT-based intervention group or to the control condition group, which receives treatment as usual. The primary outcome measure is depression in the patient with Alzheimer’s disease. The secondary outcome measures for a person with Alzheimer’s disease are other neuropsychiatric symptoms, quality of life and coping strategies. The secondary outcome measures for a caregiver are caregiver’s burden, depression, anxiety, anger, quality of life and coping strategies. Neuropsychological testing includes tests of cognitive function and activities of daily living and a global clinical assessment of severity. Participants in both groups will be assessed before and after the treatment phase (lasting approximately 9 months). Follow-up assessments will take place 6 and 12 months after treatment. All assessments will be conducted by blinded assessors.

Discussion

This trial has the potential to establish an empirically based psychological treatment for non-cognitive symptoms that reduce the quality of life of a person with dementia and a caregiver. This treatment approach focuses not only on the person with dementia, but also on the caregiver and on the dyad. The treatment manual will be published and training workshops will be offered, so that the information can be widely spread among healthcare professionals.

Trial registration

ClinicalTrials.gov NCT01273272.

Preserving Identity and Planning for Advance Care (PIPAC): preliminary outcomes from a patient-centered intervention for individuals with mild dementia

OBJECTIVES

The purpose of this pilot study was to conduct limited-efficacy testing of the newly developed Preserving Identity and Planning for Advance Care (PIPAC) intervention on self-reported and proxy-reported emotional and health-related outcomes of individuals in the early stages of dementia.

METHOD

A two-group comparison design was implemented. Blocked randomization was used to assign individuals with mild dementia and a family contact to either (1) the four-session, multi-component intervention group focused on reminiscence and future planning or (2) the minimal support phone contact comparison group. Of the 19 enrolled dyads, 18completed post-treatment assessments (i.e. 10 intervention and 8 comparison group). Individuals with dementia were M=82.8 (SD=6.46) years old; 31.6% were men and 68.4% were women. Participants were predominantly white/Caucasian (n=18, 94.7%) with one black/African-American (5.3%).

RESULTS

Analyses of covariance controlling for baseline differences revealed clinically meaningful differences (with medium to large effect sizes) between groups at post-treatment for depressive symptoms, quality of life, health-related quality of life indicators, and decisional conflict. Individuals in the intervention group were also observed to exhibit higher levels of coping. Feasibility data collected from participants and interventionists were encouraging.

CONCLUSION

Emotion-focused, patient-centered interventions like PIPAC hold promise for advancing treatment options in the early and mild stages of dementia. A full-scale, randomized clinical trial of this intervention is warranted to determine both short-term and long-term impacts on clinical outcomes including improved depressive symptomatology, quality of life, and health-related factors that impact daily functioning in social environments.

Efficacy of short-term inpatient rehabilitation for dementia patients and caregivers: prospective cohort study

BACKGROUND/AIMS

The efficacy of nonpharmacological and multicomponent treatments in patients with dementia is under discussion, as is the ongoing debate which endpoints best measure efficacy.

METHODS

194 dyads of dementia patients and their proxies interested in a combined short-term inpatient rehabilitative treatment were assessed in the patients' homes.

RESULTS

Analysis showed that cognition in male patients (cognitive part of the Alzheimer's Disease Assessment Scale: p = 0.048) and depressive mood in female patients were improved after treatment at the 3-month follow-up (Geriatric Depression Scale: p = 0.030). Moreover, the burden on male caregivers was reduced (behavioral pathology in Alzheimer's Disease Rating Scale: p = 0.002) at 3 months.

CONCLUSION

Combined short-term rehabilitative treatment of patients and psychosocial intervention for caregivers is modestly effective in patients with dementia and their caregivers, but may be subject to gender-specific effects.

Staging dementia using proxy-reported activities of daily living

BACKGROUND/AIM

It has been questioned whether cognitive and behavioral scales sufficiently address the impact of dementia on the everyday life of patients. Therefore, other instruments are used, such as scales of activities of daily living (ADL). Our goal was to analyze variables influencing the appraisal of ADL.

METHOD

Prospective cohort study on 202 patients with dementia and their proxies.

RESULTS

Two clusters of patients were identified. These clusters differed significantly in their constituting variables and all variables that informants reported regarding the patients. However, severity of dementia and other variables were similar in the two clusters.

CONCLUSION

We conclude that ratings of basic and instrumental ADL by proxy are modulated by the informants' variables, particularly if these informants are female. Use of ADL scales to assess the impact of dementia or treatment thereof needs to be handled cautiously.

Personalised caregiver support: effectiveness of psychosocial interventions in subgroups of caregivers of people with dementia

OBJECTIVE

Insight into the characteristics of caregivers for whom psychosocial interventions are effective is important for care practice. Until now no systematic reviews were conducted into the effectiveness of psychosocial interventions for caregiver subgroups.

METHODS

To gain insight into this relationship between caregiver subgroups and intervention outcomes, a first review study was done. This study reviews the personal characteristics of caregivers of people with dementia for whom psychosocial interventions were effective.

RESULTS

Electronic databases and key articles were searched for reviews on psychosocial interventions for caregivers studies published between January 1990 and February 2008. Based on these reviews, twenty-six studies met the inclusion criteria (i.e. having positive outcomes described in subgroups). Most positive effects were found in caregivers of people with a diagnosis of 'dementia not otherwise specified' and in the subgroup of female caregivers. Examples of outcomes were decreased depression and improved self-efficacy.

CONCLUSIONS

This study gives a first overview of successful psychosocial interventions in subgroups of caregivers of people with dementia. It makes clear that until now, relatively little research has been done into subgroups of these caregivers. It also suggests that more research is needed to better understand which psychosocial interventions are effective for specific subgroups of caregivers of people with dementia.

Studying the self in people with dementia: How might we proceed?

The impact of dementia on the self has become the subject of much research over the last few years, mainly due to the implications for support and care for people with dementia. However, there are a number of limitations of this research that make it difficult to integrate the existing evidence and to draw any firm conclusions regarding the persistence of self. This highlights the need for a different approach to studying the self in people with dementia in order to obtain more robust evidence from future studies. This paper attempts to integrate current research using an existing systematic and comprehensive framework of the self, and outlines the advantages and limitations of using such a framework as the basis for future studies.

Effectiveness of personalised reminiscence photo videos for individuals with dementia

Reminiscence intervention is effective for increasing self-esteem and decreasing behavioural disturbances in individuals with dementia. This paper introduces the concept of a "personalised reminiscence photo video" as a convenient method for reminiscence intervention. The video utilises a slideshow video of personal photos with narration, background music, and pan/zoom visual effects. A group of 15 individuals with dementia watched personalised reminiscence photo videos as well as two types of TV shows: a variety show and a news show. Eighty percent of the subjects (12 out of 15) showed more attention to their personalised reminiscence photo video than to the other two types of TV shows, thus suggesting the effectiveness of personalised reminiscence photo videos for reminiscence intervention.

Personalized dementia care: proven effectiveness of psychosocial interventions in subgroups

Many psychosocial intervention studies report effects in subgroups of people with dementia. Insight into the characteristics of these subgroups is important for care practice. This study reviews personal characteristics of people with dementia (living in the community or in an institution) that are related to positive outcomes of psychosocial interventions. Electronic databases and key articles were searched for effect studies published between January 1990 and February 2008. Outcome measures were clustered into categories such as cognitive functioning, behavioural functioning and mental health. Seventy-one studies showed positive outcomes on psychosocial interventions, such as decreased depression and less behavioural problems, related to personal characteristics of people with dementia, such as gender, type or severity of dementia, presence of behavioural or mental health problems, and living situation. For people with dementia living in the community positive effects were most frequently found in the persons with mild to severe dementia not otherwise specified and with mild to moderate Alzheimer's Disease. For people with dementia living in an institution positive effects were found most frequently in the subgroups moderate to severe dementia, severe to very severe dementia and in the subgroup with behavioural problems. This study provides a unique overview of characteristics that are related to effective intervention outcomes. It also suggests that more research will lead to a better understanding of which care and welfare interventions are effective for specific subgroups of people with dementia.

Improving care for patients with dementia hospitalized for acute somatic illness in a specialized care unit: a feasibility study

BACKGROUND

Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes.

METHODS

The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design).

RESULTS

332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 +/- 8.3 vs. 15.0 +/- 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001).

CONCLUSIONS

The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.

A special care unit for acutely ill patients with dementia and challenging behaviour as a model of geriatric care

This paper describes the development and management of a new model of care for hospitalized patients with challenging behaviour evoked by dementia and/or delirium. To ameliorate care for patients with dementia in a geriatric acute care hospital a segregated Special Care Unit for patients with challenging behaviour was created. Environmental features allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Day-time activities structure the day and assure additional professional presence in the unit. An intensive training program for the staff was provided. The SCU has been well accepted by the staff and is considered to be an improvement in care. Psychological burden of the nurses did not increase over a time period of one year in caring for these difficult patients.

Systematic review of the effect of psychological interventions on family caregivers of people with dementia

BACKGROUND

Caregivers of people with dementia are at high risk of psychological morbidity and associated breakdown in care. Many psychologically based interventions have been designed to help caregivers of people with dementia. More work is needed to identify which, if any, are helpful for such caregivers.

METHOD

We conducted a systematic review of the immediate and long term efficacy of different types of psychological interventions for the psychological health of caregivers of people with dementia, using standardized criteria, to assist clinicians in implementing rational, evidence-based management recommendations. We reviewed studies examining the effects of any therapy derived from a psychological approach that satisfied pre-specified criteria. Using the Oxford Centre for Evidence-Based Medicine criteria we rated the quality of each study, extracted data and gave overall ratings to different types of intervention.

RESULTS

We identified 244 references in our search of which 62 met our inclusion criteria.

LIMITATIONS

Our findings are limited by lack of good quality evidence, with only ten level 1 studies identified.

CONCLUSIONS

We found excellent evidence for the efficacy of six or more sessions of individual behavioral management therapy centered on the care recipient's behavior in alleviating caregiver symptoms both immediately and for up to 32 months. Teaching caregivers coping strategies either individually or in a group also appeared effective in improving caregiver psychological health both immediately and for some months afterwards. Group interventions were less effective than individual interventions. Education about dementia by itself, group behavioral therapy and supportive therapy were not effective caregiver interventions.

Successful guidance by automatic output of music and verbal messages for daily behavioural disturbances of three individuals with dementia

There have been no previous reports of daily home activities of individuals with dementia being guided by the combination of music and verbal messages. This study evaluated the effectiveness for three individuals of music and messages which were automatically output by an IC recorder. After music was presented, messages instructed the participants to go to a day care centre, behave more peacefully and eat more at meals, respectively. These stimuli were highly effective for guiding the above activities. This study suggests that automatic output of music and messages has potential as a strategy for guiding individuals with dementia at their home. For the third individual, the music and messages were output through a doll. The implications of using a doll are also discussed.

Illness representations and lived experience in early-stage dementia

The self-regulation model of illness behavior provides a framework for understanding how threats to self from chronic illness can be managed and proposes a significant role for illness representations. This framework can assist in illuminating the experience of developing dementia but has not previously been considered in this context. The authors conducted semistructured interviews with 9 people who had a diagnosis of early-stage dementia to explore illness representations and how these related to daily lived experience, using interpretative phenomenological analysis (IPA). Two over arching themes emerged: It will get worse, reflecting an understanding of dementia; and I want to be me, reflecting a desire to maintain sense of identity. Participants faced a number of personal and interpersonal dilemmas. The authors present a preliminary model of the way in which illness representations contribute to the lived experience of early-stage dementia.

Cognitive rehabilitation combined with drug treatment in Alzheimer's disease patients: a pilot study

OBJECTIVE

To study the efficacy of cognitive rehabilitation combined with acetylcholinesterase inhibitor (AChE-I) treatment in patients with mild Alzheimer's disease and their relatives.

METHOD

Thirteen patients with mild Alzheimer's disease treated with rivastigmine 6-12 mg/day for more than two months started cognitive rehabilitation training. Before and after the cognitive rehabilitation training patients were assessed through cognitive tests, activities of daily living scale, neuropsychological battery and scales to evaluate caregivers' depressive and anxiety symptoms. Six patients were randomized to a combined treatment group (AChE-I plus cognitive rehabilitation and caregiver support) and seven patients to a control group (AChE-I only) and followed up for five months.

RESULTS

Mini-Mental State Examination (MMSE) scores (p = 0.047) and backward digit span scores (p = 0.018) were significantly different between the groups on follow-up. The combined treatment group showed a better positive treatment effect on cognitive and neuropsychological tests applied to patients and reduction of psychiatric symptoms was observed in their caregivers (nonsignificant).

CONCLUSION

Cognitive rehabilitation associated with AChE-I treatment can potentially be useful to stabilize or improve cognitive and functional performance of patients with mild Alzheimer's disease and can reduce caregivers' psychiatric symptoms.

Selbsterhaltungstherapie: Konzept, klinische Praxis und bisherige Ergebnisse

Zusammenfassung: Mit der Selbsterhaltungstherapie (SET) wurde ein (neuro)psychologisch fundiertes Rehabilitationsprogramm für Demenzkranke, insbesondere für Personen mit einer Alzheimer Demenz, konzipiert und in dieser Zeitschrift zum ersten Mal veröffentlicht ( Romero & Eder, 1992 ). Als übergeordnetes Rehabilitationsziel wurde die Erhaltung des Selbst in seiner Kohärenz und Funktionsfähigkeit eingeführt. Die SET fand Anwendung in der klinischen Praxis, sowohl im ambulanten und stationären Bereich wie in Heimen. Die meisten Erfahrungen liegen aus dem Alzheimer Therapiezentrum (ATZ) Bad Aibling vor. Das ATZ bietet stationär medikamentöse Behandlung in Verbindung mit einem Rehabilitationsprogramm für Demenzkranke und einem psychoedukativen Programm für betreuende Angehörige an. Die Ergebnisse der bisherigen begleitenden empirischen Studien zeigen eine Verbesserung des Wohlbefindens (z. B. der Depressivität) nach der Behandlung, sowohl bei Kranken als auch bei Angehörigen. Mögliche Wirkmechanismen des therapeutischen Erfolges werden diskutiert.

Non-drug therapies for dementia: an overview of the current situation with regard to proof of effectiveness

An overview will be presented of music therapy, art therapy, movement therapy and reminiscence therapy, memory training, reality orientation, validation therapy, self-maintenance therapy, behaviour therapy, milieu therapy and staff training. The overview will examine the aims of each, the principles on which procedures are based and the proof of their effectiveness. The principal aim of non-drug therapies is to influence symptomatic dementia beneficially and to improve the abilities remaining to the patient. The potential benefits are usually deduced from studies made without control groups. At the present time, proof of the effectiveness of these therapies is still lacking as controlled, randomized studies have yet to be conducted, and so a fundamental evaluation of the therapeutic benefits of non-drug therapies in the treatment of dementia cannot yet be made.