Nonpharmacological management of apathy in dementia: a systematic review

Relationship between mortality and vitality in patients with mild cognitive impairment/dementia: An 8-year retrospective study

AIM

The study aimed to investigate the association of vitality, as measured using the vitality index (Vix), with the survival outcomes of older adults with mild cognitive impairment (MCI) or dementia.

METHODS

We analyzed data from 3731 patients in the National Center for Geriatrics and Gerontology - Life Stories of Individuals with Dementia cohort from July 2010 to September 2018. The main focus was to correlate Vix scores with the time from the initial visit to death. Vix was categorized into "moderately to severely impaired" (0-7 points), "mildly impaired" (8-9 points), and "normal" (10 points) groups. Survival outcomes were assessed using a Cox proportional hazards model, adjusted for various factors. We conducted a mediation analysis to evaluate the effect of body mass index (BMI), instrumental activities of daily living (IADL), and basic activities of daily living (BADL) on the association between vitality and mortality. Stratified analysis was also conducted for the Mini-Mental State Examination groups.

RESULTS

We included 2740 patients with an average follow-up of 1315 days. The mortality rate was 15.7%. The Vix distribution was 16% at 0-7 points; 40%, 8-9 points; and 44%, 10 points. Patients in the "moderately to severely impaired" category, characterized by lower Vix scores, exhibited notably higher mortality rates. Mediation effects emphasized the significant roles of BMI, IADL, and BADL in influencing survival outcomes.

CONCLUSIONS

Vitality significantly influences patient survival rates. The association between vitality and mortality seems to be mediated by IADL and BADL, which has significant clinical implications. Geriatr Gerontol Int 2024; 24: 221-228.

Vascular cognitive impairment: When memory loss is not the biggest challenge

OBJECTIVES

Vascular cognitive impairment is the second most common type of cognitive impairment. Care needs of community-dwelling people with vascular cognitive impairment and their caregivers have not been thoroughly studied. Therefore, we aimed to explore care needs of people with vascular cognitive impairment and their family caregivers.

DESIGN

A qualitative interview study.

SETTING AND PARTICIPANTS

Participants were purposefully sampled community-dwelling people with vascular cognitive impairment and their family caregivers.

METHODS

Interviews were audiotaped and transcribed verbatim. Analysis and data collection followed an iterative process, until data saturation was achieved. We conducted 18 interviews (nine people with vascular cognitive impairment and nine caregivers), concerning 13 unique people with vascular cognitive impairment. We analyzed the data using inductive thematic analysis following the Braun & Clark method. The study was reported in accordance with the COREQ criteria.

FINDINGS

Five themes were identified in the care needs reported by people with vascular cognitive impairment and family caregivers: (1) Specific information need with subtheme (1A) No memory problem, no dementia? (2) Being respected as a person, (3) Differing concerns about the future, (4) The roles of the caregiver and (5) Decisiveness from professional healthcare.

CONCLUSIONS AND IMPLICATIONS

The care needs of people with vascular cognitive impairment and their caregivers were affected by (a lack of knowledge about) the characteristic symptoms of this condition. Participants equated cognitive impairment or dementia to memory loss ("Alzheimerization"), although memory loss was not their biggest challenge. People with vascular cognitive impairment and caregivers preferred resolute and decisive healthcare professionals. These professionals activate the person with vascular cognitive impairment who lacks initiative and diminishe role conflict of the caregiver. Care for people with vascular cognitive impairment and their caregivers could be improved by providing tailored information, promoting awareness of neuropsychiatric symptoms, particularly apathy, and by healthcare professionals providing more guidance in decision-making.

Alterations of Audiovisual Integration in Alzheimer's Disease

Audiovisual integration is a vital information process involved in cognition and is closely correlated with aging and Alzheimer's disease (AD). In this review, we evaluated the altered audiovisual integrative behavioral symptoms in AD. We further analyzed the relationships between AD pathologies and audiovisual integration alterations bidirectionally and suggested the possible mechanisms of audiovisual integration alterations underlying AD, including the imbalance between energy demand and supply, activity-dependent degeneration, disrupted brain networks, and cognitive resource overloading. Then, based on the clinical characteristics including electrophysiological and imaging data related to audiovisual integration, we emphasized the value of audiovisual integration alterations as potential biomarkers for the early diagnosis and progression of AD. We also highlighted that treatments targeted audiovisual integration contributed to widespread pathological improvements in AD animal models and cognitive improvements in AD patients. Moreover, investigation into audiovisual integration alterations in AD also provided new insights and comprehension about sensory information processes.

Epidemiology of Motoric Cognitive Risk Syndrome in the Kerala Einstein Study: Protocol for a Prospective Cohort Study

BACKGROUND

The southern India state of Kerala has among the highest proportion of older adults in its population in the country. An increase in chronic age-related diseases such as dementia is expected in the older Kerala population. Identifying older individuals early in the course of cognitive decline offers the best hope of introducing preventive measures early and planning management. However, the epidemiology and pathogenesis of predementia syndromes at the early stages of cognitive decline in older adults are not well established in India.

OBJECTIVE

The Kerala Einstein Study (KES) is a community-based cohort study that was established in 2008 and is based in the Kozhikode district in Kerala state. KES aims to establish risk factors and brain substrates of motoric cognitive risk syndrome (MCR), a predementia syndrome characterized by the presence of slow gait and subjective cognitive concerns in individuals without dementia or disability. This protocol describes the study design and procedures for this KES project.

METHODS

KES is proposing to enroll a sample of 1000 adults ≥60 years old from urban and rural areas in the Kozhikode district of Kerala state: 200 recruited in the previous phase of KES and 800 new participants to be recruited in this project. MCR is the cognitive phenotype of primary interest. The associations between previously established risk factors for dementia as well as novel risk factors (apathy and traumatic brain injury) and MCR will be examined in KES. Risk factor profiles for MCR will be compared between urban and rural residents as well as with individuals who meet the criteria for mild cognitive impairment (MCI). Cognitive and physical function, medical history and medications, sociodemographic characteristics, lifestyle patterns, and activities of daily living will be evaluated. Participants will also undergo magnetic resonance imaging and electrocardiogram investigations. Longitudinal follow-up is planned in a subset of participants as a prelude to future longitudinal studies.

RESULTS

KES (2R01AG039330-07) was funded by the US National Institutes of Health in September 2019 and received approval from the Indian Medical Council of Research to start the study in June 2021. We had recruited 433 new participants from urban and rural sites in Kozhikode as of May 2023: 41.1% (178/433) women, 67.7% (293/433) rural residents, and 13.4% (58/433) MCR cases. Enrollment is actively ongoing at all the KES recruitment sites.

CONCLUSIONS

KES will provide new insights into risk factors and brain substrates associated with MCR in India and will help guide future development of regionally specific preventive interventions for dementia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49933.

[Les effets de l'environnement de soins sur les comportements réactifs des personnes ayant des troubles neurocognitifs vivant en centre d'hébergement : Une revue de la portée]

Les personnes âgées atteintes de troubles neurocognitifs (démences) vivant en centre d'hébergement adoptent fréquemment des comportements réactifs qui limitent leur engagement dans des occupations. La présente étude vise à identifier des moyens d'intervention centrés sur l'engagement des personnes âgées ayant un trouble neurocognitif avec l'environnement humain et non humain en centre d'hébergement afin de diminuer leurs comportements réactifs, en particulier les comportements d'errance, d'apathie et d'agitation. Cette revue de la portée est basée sur la méthode proposée par Levac et ses collaborateurs (2010). Parmi les 21 études retenues, la plupart s'intéressent à des interventions ciblant l'environnement non humain (n=9) ou ciblant simultanément l'environnement humain et non humain (n=9). Plusieurs de ces interventions sont efficaces pour diminuer les comportements réactifs et permettent aux personnes âgées de s'engager avec leur environnement. Le support de l'environnement humain semble toutefois nécessaire à l'utilisation optimale de plusieurs interventions.

Distinguishing apathy from depression: A review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders

OBJECTIVES

This narrative review describes the clinical features of apathy and depression in individuals with neurocognitive disorders (NCDs), with the goal of differentiating the two syndromes on the basis of clinical presentation, diagnostic criteria, neuropathological features, and contrasting responses to treatments.

METHODS

Literature was identified using PubMed, with search terms to capture medical conditions of interest; additional references were also included based on our collective experience and knowledge of the literature.

RESULTS

Evidence from current literature supports the distinction between the two disorders; apathy and depression occur with varying prevalence in individuals with NCDs, pose different risks of progression to dementia, and have distinct, if overlapping, neurobiological underpinnings. Although apathy is a distinct neuropsychiatric syndrome, distinguishing apathy from depression can be challenging, as both conditions may occur concurrently and share several overlapping features. Apathy is associated with unfavorable outcomes, especially those with neurodegenerative etiologies (e.g., Alzheimer's disease) and is associated with an increased burden for both patients and caregivers. Diagnosing apathy is important not only to serve as the basis for appropriate treatment, but also for the development of novel targeted interventions for this condition. Although there are currently no approved pharmacologic treatments for apathy, the research described in this review supports apathy as a distinct neuropsychiatric condition that warrants specific treatments aimed at alleviating patient disability.

CONCLUSIONS

Despite differences between these disorders, both apathy and depression pose significant challenges to patients, their families, and caregivers; better diagnostics are needed to develop more tailored treatment and support.

The neurobiology of apathy in depression and neurocognitive impairment in older adults: a review of epidemiological, clinical, neuropsychological and biological research

Apathy is a common condition that involves diminished initiative, diminished interest and diminished emotional expression or responsiveness. It is highly prevalent in the context of a variety of neuropsychiatric disorders and is related to poor health outcomes. Presence of apathy is associated with cognitive and functional decline in dementia. Despite its negative impact on health, there is no definitive treatment for apathy, a clinical reality that may be due in part to lack of knowledge about assessment, neuropsychological features and neurobiological underpinnings. Here, we review and synthesize evidence from clinical, epidemiological, neuropsychological, peripheral biomarker and neuroimaging research. Apathy is a common feature of depression and cognitive disorders and is associated with impairment in executive function. Neuropsychological and neuroimaging studies point to dysfunction of brain circuitry involving the prefrontal cortex, especially the dorsolateral prefrontal cortex circuit, the dorsomedial prefrontal cortex circuit, and the ventromedial prefrontal cortex circuit. However, inconsistent findings, particularly in neuroimaging may be due to heterogeneity of apathy symptoms (with a need to better elucidate subtypes), neuropsychiatric comorbidities, the severity of cognitive impairment and other factors. These factors need to be accounted for in future studies so that biomarker research can make progress. On the whole, the literature on apathy has identified likely neurocognitive, peripheral biomarker and neuroimaging targets for understanding apathy, but also points to the need to address methodological issues that will better inform future studies. In turn, as we learn more about the underpinning of apathy and its subtypes, subsequent research can focus on new neurally based interventions that will strengthen the clinical management of apathy in the context of its comorbidities.

Altered reward processing underpins emotional apathy in dementia

Introduction

While apathy is broadly defined as a loss of motivation, it is increasingly recognised as a multidimensional syndrome spanning executive, emotional, and initiation domains. Emotional apathy is purportedly driven by deficits in using socioemotional rewards to guide behaviour, yet the link between these symptoms and reward processing, and their common neural correlates, has not been directly examined.

Methods

Sixty-four patients (33 behavioural-variant frontotemporal dementia, 14 Alzheimer’s disease, 8 semantic dementia, 6 progressive nonfluent aphasia, 3 logopenic progressive aphasia) were classified into high (HEA; n = 36) and low (LEA; n = 28) emotional apathy groups based on emotional apathy subscale scores on the Dimensional Apathy Scale. Patients and age-matched healthy controls (n = 27) performed an instrumental reward learning task where they learned to associate cues with either social or monetary outcomes.

Results

HEA patients showed impaired learning on both the social and monetary reward conditions, relative to LEA patients (p = 0.016) and controls (p = 0.005). Conversely, the LEA group did not differ from controls (p = 0.925). Importantly, multiple regression analyses indicated that social reward learning significantly predicted emotional apathy. Voxel-based morphometry analyses revealed that emotional apathy and social reward learning were both associated with orbitofrontal cortex, ventral striatum, and insula atrophy.

Discussion

Our results demonstrate a unique link between impaired social reward learning and emotional apathy in dementia and reveal a shared neurobiological basis. Greater understanding of these neurocognitive mechanisms of reward processing will help improve the identification of emotional apathy in dementia and inform the development of novel interventions to address these symptoms.

Fun and a meaningful routine: the experience of physical activity in people with dementia

Background

Physical activity is important to health and wellbeing. People with dementia are less physically active than their cognitively healthy counterparts. Reasons for this are multifaceted, and are thought to be social, psychological, and physiological. People with dementia often use services such as home care, day care centres and nursing home, and according to the stage of disease they are less or more dependent on other people to take part in activities. To develop appropriate services to this patient group, their needs and preferences regarding physical activity must be recognized. The aim of the study was therefore to provide insight into experiences with physical activity in people with dementia.

Methods

The current study is part of a larger research project on needs in people with dementia. The main project included qualitative semi-structured interviews with 35 persons with dementia. 27 of the participants talked about their experience with physical activity. In the current study, the relevant findings on this theme were analysed separately. A phenomenological hermeneutic research design was applied.

Results

The analysis revealed three main categories regarding experiences with physical activity. To be physically active provided positive experiences such as feelings of mastering and post-exercise euphoria. To be physically active was meaningful. The daily walk was an important routine to many, and it gave meaningful content to the day. Keeping up with activities confirmed identity. Lastly, to be active was perceived as challenging. Participants described different barriers to being physically active such as a decline of physical function, lack of motivation and being dependent on others to go out.

Conclusions

Many of the participants expressed that being physically active was important to them. It is essential that informal and formal carers are aware of the role physical activity plays in the lives of many people with dementia, so that appropriate measures can be taken to assure continued active living in order to preserve health and quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03149-6.

SAR-Connect: A Socially Assistive Robotic System to Support Activity and Social Engagement of Older Adults

Multi-domain activities that incorporate physical, cognitive, and social stimuli can enhance older adults' overall health and quality of life. Several robotic platforms have been developed to provide these therapies in a quantifiable manner to complement healthcare personnel in resource-strapped long-term care settings. However, these platforms are primarily limited to one-to-one human robot interaction (HRI) and thus do not enhance social interaction. In this paper, we present a novel HRI framework and a realized platform called SAR-Connect to foster robot-mediated social interaction among older adults through carefully designed tasks that also incorporate physical and cognitive stimuli. SAR-Connect seamlessly integrates a humanoid robot with a virtual reality-based activity platform and a multimodal data acquisition module including game interaction, audio, visual and electroencephalography responses of the participants. Results from a laboratory-based user study with older adults indicates the potential of SAR-Connect that showed this system could 1) involve one or multiple older adults to perform multi-domain activities and provide dynamic guidance, 2) engage them in the robot-mediated task and foster human-human interaction, and 3) quantify their social and activity engagement from multiple sensory modalities.

Prevalence and type of unmet needs experienced by carers of people living with dementia

OBJECTIVES

Carers of people with dementia experience significant physical, emotional, and social burdens. Needs assessment can provide important information to assist services in providing support to carers to reduce these burdens. However, few studies have examined the prevalence of unmet needs experienced by carers of people with dementia using a quantitative instrument. This study aimed to examine the prevalence and type of unmet needs experienced by carers of people with dementia in Australia.

METHODS

This was a cross-sectional survey of carers providing support to community-dwelling individuals living with dementia. Carers were recruited through geriatric clinics, aged care providers, support services and community organisations. Consenting carers completed a survey including an 80-item study-specific unmet needs instrument for carers (UNI-C) and sociodemographic characteristics. Descriptive statistics were used to identify the most prevalent unmet needs reported by carers.

RESULTS

A total of 169 carers (response rate 47%) completed the survey. Most (87%) carers reported at least one unmet need. Carers reported a median of 16.0 (IQR = 24.0; max = 58) out of a possible 80 unmet needs. The most frequently endorsed unmet needs spanned a range of areas including emotional wellbeing, accessing health and aged care services, managing apathy, and finding information.

CONCLUSION

This study highlighted that a large proportion of carers experience unmet needs associated with caring for someone with dementia. Developing and rigorously testing interventions to meet carers' commonly reported unmet needs are warranted.

Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2053833 .

Dissociable Functional Brain Networks Associated With Apathy in Subcortical Ischemic Vascular Disease and Alzheimer’s Disease

Few studies have investigated differences in functional connectivity (FC) between patients with subcortical ischemic vascular disease (SIVD) and Alzheimer’s disease (AD), especially in relation to apathy. Therefore, the aim of this study was to compare apathy-related FC changes among patients with SIVD, AD, and cognitively normal subjects. The SIVD group had the highest level of apathy as measured using the Apathy Evaluation Scale-clinician version (AES). Dementia staging, volume of white matter hyperintensities (WMH), and the Beck Depression Inventory were the most significant clinical predictors for apathy. Group-wise comparisons revealed that the SIVD patients had the worst level of “Initiation” by factor analysis of the AES. FCs from four resting state networks (RSNs) were compared, and the connectograms at the level of intra- and inter-RSNs revealed dissociable FC changes, shared FC in the dorsal attention network, and distinct FC in the salient network across SIVD and AD. Neuronal correlates for “Initiation” deficits that underlie apathy were explored through a regional-specific approach, which showed that the right inferior frontal gyrus, left middle frontal gyrus, and left anterior insula were the critical hubs. These findings broaden the disconnection theory by considering the effect of FC interactions across multiple RSNs on apathy formation.

Pharmacological Management of Apathy in Dementia

Apathy is a highly prevalent symptom of dementia. Despite its association with faster cognitive and functional decline, decreased quality of life and increased mortality, no therapies are currently approved to treat apathy. The objective of this review was to summarize the drugs that have been studied for apathy treatment in patients with dementia (specifically Alzheimer's disease [AD], Huntington's disease [HD] and Parkinson's disease [PD] dementia; dementia with Lewy bodies [DLB]; vascular dementia [VaD]; and frontotemporal dementia [FTD]) based on their putative mechanisms of action. A search for relevant studies was performed using ClinicalTrials.gov and PubMed. Eligible studies were randomized controlled trials that were available in English and included at least one drug intervention and an apathy measure scale. A total of 52 studies that included patients with AD (n = 33 studies), PD (n = 5), HD (n = 1), DLB (n = 1), FTD (n = 3), VaD (n = 1), VaD and AD (n = 4), VaD and mixed dementia (n = 1), and AD, VaD and mixed dementia (n = 3) were eligible for inclusion. These studies showed that methylphenidate, olanzapine, cholinesterase inhibitors, choline alphoscerate, citalopram, memantine, and mibampator are the only beneficial drugs in AD-related apathy. For PD-related apathy, only methylphenidate, rotigotine and rivastigmine showed benefits. Regarding FTD- and DLB-related apathy, initial studies with agomelatine and rivastigmine showed benefits, respectively. As for HD- and only-VaD-related apathy, no drugs demonstrated benefits. With regards to mixed populations, memantine, galantamine and gingko biloba showed effects on apathy in the AD plus VaD populations and nimodipine in the VaD plus mixed dementia populations. Of the drugs with positive results, some are already prescribed to patients with dementia to target other symptoms, some have characteristics-such as medical contraindications (e.g., cardiovascular) and adverse effects (e.g., gastrointestinal disturbances)-that limit their clinical use and some require further study. Future studies should investigate apathy as a primary outcome, making use of appropriate sample sizes and study durations to ensure durability of results. There should also be a consensus on using scales with high test/retest and interrater reliabilities to limit the inconsistencies between clinical trials. In conclusion, there are currently no US FDA-approved drugs that target apathy in dementia, so there is an ongoing need for the development of such drugs.

A tablet-based intervention for activating nursing home residents with dementia: results from a cluster-randomized controlled trial

OBJECTIVES

To investigate global and momentary effects of a tablet-based non-pharmacological intervention for nursing home residents living with dementia.

DESIGN

Cluster-randomized controlled trial.

SETTING

Ten nursing homes in Germany were randomly allocated to the tablet-based intervention (TBI, 5 units) or conventional activity sessions (CAS, 5 units).

PARTICIPANTS

N = 162 residents with dementia.

INTERVENTION

Participants received regular TBI (n = 80) with stimulating activities developed to engage people with dementia or CAS (n = 82) for 8 weeks.

MEASUREMENTS

Apathy Evaluation Scale (AES-I, primary outcome), Quality of Life in Alzheimer's Disease scale, QUALIDEM scale, Neuropsychiatric Inventory, Geriatric Depression Scale, and psychotropic medication (secondary outcomes). Momentary quality of life was assessed before and after each activity session. Participants and staff were blinded until the collection of baseline data was completed. Data were analyzed with linear mixed-effects models.

RESULTS

Levels of apathy decreased slightly in both groups (mean decrease in AES-I of .61 points, 95% CI -3.54, 2.33 for TBI and .36 points, 95% CI -3.27, 2.55 for CAS). Group difference in change of apathy was not statistically significant (β = .25; 95% CI 3.89, 4.38, p = .91). This corresponds to a standardized effect size (Cohen's d) of .02. A reduction of psychotropic medication was found for TBI compared to CAS. Further analyses revealed a post-intervention improvement in QUALIDEM scores across both groups and short-term improvements of momentary quality of life in the CAS group.

CONCLUSIONS

Our findings suggest that interventions involving tailored activities have a beneficial impact on global and momentary quality of life in nursing home residents with dementia. Although we found no clear advantage of TBI compared to CAS, tablet computers can support delivery of non-pharmacological interventions in nursing homes and facilitate regular assessments of fluctuating momentary states.

Apathy as a Treatment Target in Alzheimer's Disease: Implications for Clinical Trials

Apathy is one of the most prevalent, stable and persistent neuropsychiatric symptom across the neurocognitive disorders spectrum. Recent advances in understanding of phenomenology, neurobiology and intervention trials highlight apathy as an important target for clinical intervention. We conducted a comprehensive review and critical evaluation of recent advances to determine the evidence-based suggestions for future trial designs. This review focused on 4 key areas: 1) pre-dementia states; 2) assessment; 3) mechanisms/biomarkers and 4) treatment/intervention efficacy. Considerable progress has been made in understanding apathy as a treatment target and appreciating pharmacological and non-pharmacological apathy treatment interventions. Areas requiring greater investigation include: diagnostic procedures, symptom measurement, understanding the biological mechanisms/biomarkers of apathy, and a well-formed approach to the development of treatment strategies. A better understanding of the subdomains and biological mechanisms of apathy will advance apathy as a treatment target for clinical trials.

Use of robots to encourage social engagement between older adults

We designed a robotic architecture system within a commercially available socially assistive robot to engage pairs of older adults in multimodal activities over 3 weeks for 6 sessions. The study took place in two assisted living facilities. Seven pairs (14 individuals) completed the experiment. Ages ranged from 70 to 90 years with a mean age of 83.0 (± 6.1). Most were women (79%). Three adults were screened as having normal cognition, 10 had mild cognitive impairment, and 1 adult self-reported a diagnosis of Alzheimer's disease. All sessions were video recorded and analyzed using Noldus Observer XT. Individuals demonstrated high levels of both human-human interaction and human-robot interaction, but the activity influenced the type of interaction. Engagement measures (visual, verbal, behavioral) also varied by type of activity. Future studies will focus on further development of activities that can engage older adults with varying levels of cognitive impairment and apathy.

Gait, physical function, and physical activity in three groups of home-dwelling older adults with different severity of cognitive impairment - a cross-sectional study

Background

The research on associations between gait, physical function, physical activity (PA), and cognitive function is growing. Still, clinical assessments of cognitive function and motor function is often kept separate. In this study, we aimed to look at a broad range of measures of gait, physical function, and PA in three groups of home-dwelling older adults with no or questionable dementia, mild dementia, and moderate/severe dementia.

Methods

This cross-sectional study included 100 home-dwelling older adults, recruited from an outpatient geriatric memory clinic. Severity of dementia was categorised using the clinical dementia rating scale (CDR), with no or questionable dementia (CDR score 0 and 0.5), mild dementia (CDR score 1) and moderate/severe dementia (CDR score 2 and 3). We used thigh worn accelerometers to measure daily PA, the Short Physical Performance Battery (SPPB) to measure physical function, and an electronic gait mat to evaluate gait characteristics. Associations between severity of dementia and measures of PA, physical function, and gait characteristics were assessed by linear regression.

Results

Participants’ (mean age 78.9 (SD 6.7) years, 57% women) average gait speed was 0.93 m/sec, and average upright time was 301 min/day. Statistically significant associations were found for the severity of dementia and gait speed (p=0.002), step time (p=0.001), physical function (SPPB, p=0.007), and PA (upright time, p=0.031), after adjusting for age. Overall, having no or questionable dementia was associated with faster gait speed (mean difference 0.163 (95% CI: 0.053 to 0.273)), shorter step time (-0.043 (-0.082 to -0.005)), better SPPB score (1.7 (0.5 to 2.8)), and longer upright time (78.9 (18.9 to 139.0)), compared to those with mild dementia. Furthermore, having no or questionable dementia was also associated with faster gait speed and better SPPB scores, as compared to those with moderate to severe dementia. No evidence of any differences was found between the participants with the mild dementia versus the moderate to severe dementia.

Conclusions

After adjusting for age, we found that the no or questionable dementia group to be associated with better gait and physical function, and more PA, as compared with the two groups with mild or moderate/severe dementia. Evaluation of gait, physical function, and PA can add clinically important information of everyday functioning in memory clinics meeting geriatric patients, but investigations on how to use these results to guide interventions are still needed.

The Effect of Reminiscence Therapy Using Virtual Reality on Apathy in Residential Aged Care: Multisite Nonrandomized Controlled Trial

Background

Apathy is a frequent and underrecognized neurological disorder symptom. Reduced goal-directed behavior caused by apathy is associated with poor outcomes for older adults in residential aged care. Recommended nonpharmacological treatments include person-centered therapy using information and communication technology. Virtual reality (VR) in the form of head-mounted displays (HMDs) is a fully immersive technology that provides access to a wide range of freely available content. The use of VR as a therapy tool has demonstrated promise in the treatment of posttraumatic stress disorder and anxiety. In addition, VR has been used to improve conditions including depression, anxiety, cognitive function, and balance in older adults with memory deficits, Alzheimer disease, and Parkinson disease. Research using VR for the symptoms of apathy in older adults living in residential aged care facilities is limited.

Objective

This study aims to examine whether using HMDs as a tool for reminiscence therapy improves the symptoms of apathy compared with using a laptop computer and physical items with older adults living in residential aged care.

Methods

In this multisite trial, 43 participants were allocated to one of three groups: reminiscence therapy intervention using VR in the form of HMDs, reminiscence therapy using a laptop computer supplemented by physical items if required (active control), and a usual care (passive control) group. The primary outcome was apathy, and the secondary outcomes included cognition and depression. The side effects of using HMDs were also measured in the VR group.

Results

Mixed model analyses revealed no significant group interaction over time in outcomes between the VR and laptop groups (estimate=−2.24, SE 1.89; t₄₀=−1.18; P=.24). Pooled apathy scores in the two intervention groups compared with the passive control group also revealed no significant group interaction over time (estimate=−0.26, SE 1.66; t₄₀=−0.16; P=.88). There were no significant secondary outcomes. Most participants in the VR group stated that they would prefer to watch content in VR than on a flat screen (Χ²₂=11.2; P=.004), side effects from HMD use were negligible to minimal according to the Simulator Sickness Questionnaire cutoff scores.

Conclusions

Although there were no significant results in outcome measures, this study found that participants engaged in the research and enjoyed the process of reminiscing using both forms of technology. It was found that VR can be implemented in an aged care setting with correct protocols in place. Providing residents in aged care with a choice of technology may assist in increasing participation in activities. We cannot dismiss the importance of immediate effects while the therapy was in progress, and this is an avenue for future research.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619001510134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378564.

International Registered Report Identifier (IRRID)

RR2-DOI: 10.1136/bmjopen-2020-046030

Adjunctive Therapy to Manage Neuropsychiatric Symptoms in Moderate and Severe Dementia: Randomized Clinical Trial Using an Outpatient Version of Tailored Activity Program

BACKGROUND

Neuropsychiatric symptoms (NPS) such as aggression, apathy, agitation, and wandering may occur in up to 90%of dementia cases. International guidelines have suggested that non-pharmacological interventions are as effective as pharmacological treatments, however without the side effects and risks of medications. An occupational therapy method, called Tailored Activity Program (TAP), was developed with the objective to treat NPS in the elderly with dementia and has been shown to be effective.

OBJECTIVE

Evaluate the efficacy of the TAP method (outpatient version) in the treatment of NPS in individuals with dementia and in the burden reduction of their caregivers.

METHODS

This is a randomized, double-blind, controlled clinical trial for the treatment of NPS in dementia. Outcome measures consisted of assessing the NPS of individuals with dementia, through the Neuropsychiatric Inventory-Clinician rating scale (NPI-C), and assessing the burden on their caregivers, using the Zarit Scale. All the participants were evaluated pre-and post-intervention.

RESULTS

54 individuals with dementia and caregivers were allocated to the experimental (n = 28) and control (n = 26) groups. There was improvement of the following NPS in the experimental group: delusions, agitation, aggressiveness, depression, anxiety, euphoria, apathy, disinhibition, irritability, motor disturbance, and aberrant vocalization. No improvement was observed in hallucinations, sleep disturbances, and appetite disorders. The TAP method for outpatient settings was also clinically effective in reducing burden between caregivers of the experimental group.

CONCLUSION

The use of personalized prescribed activities, coupled with the caregiver training, may be a clinically effective approach to reduce NPS and caregiver burden of individuals with dementia.

ECOCAPTURE@HOME: Protocol for the Remote Assessment of Apathy and Its Everyday-Life Consequences

Apathy, a common neuropsychiatric symptom associated with dementia, has a strong impact on patients’ and caregivers’ quality of life. However, it is still poorly understood and hard to define. The main objective of the ECOCAPTURE programme is to define a behavioural signature of apathy using an ecological approach. Within this program, ECOCAPTURE@HOME is an observational study which aims to validate a method based on new technologies for the remote monitoring of apathy in real life. For this study, we plan to recruit 60 couples: 20 patient-caregiver dyads in which patients suffer from behavioral variant Fronto-Temporal Dementia, 20 patient-caregiver dyads in which patients suffer from Alzheimer Disease and 20 healthy control couples. These dyads will be followed for 28 consecutive days via multi-sensor bracelets collecting passive data (acceleration, electrodermal activity, blood volume pulse). Active data will also be collected by questionnaires on a smartphone application. Using a pool of metrics extracted from these passive and active data, we will validate a measurement model for three behavioural markers of apathy (i.e., daytime activity, quality of sleep, and emotional arousal). The final purpose is to facilitate the follow-up and precise diagnosis of apathy, towards a personalised treatment of this condition within everyday life.

Association between apathy and satisfaction with meaningful activities in older adults with mild cognitive impairment: A population-based cross-sectional study

OBJECTIVES

This cross-sectional study aimed to clarify the relationship between apathy, meaningful activities, and satisfaction with such activities of older adults with mild cognitive impairment (MCI).

METHODS

We analyzed 235 older adults with MCI (≥65 years, mean age: 76.9 ± 6.4 years, women: 63.4%) who participated in a community-based health check survey (Tarumizu Study 2018). MCI was defined as at least 1.5 SD below the reference threshold (age- and education-adjusted score) on one or more of the computerized cognitive test including memory, attention, executive functions, and processing speed. Apathy symptoms were assessed using three of the 15 items of Geriatric Depression Scale. Participants selected meaningful activities from the 95 activities of the Aid for Decision-Making in Occupation Choice and evaluated their satisfaction and performance.

RESULTS

Apathy in MCI was prevalent by 23.8%. The categories of meaningful activities revealed no difference, with, or without apathy. Logistic regression analysis showed that activity satisfaction was significantly associated with apathy after adjusting for age, sex, education, instrumental activities of daily living, depressive symptoms, and MCI subtype (OR, 0.62; 95% CI, 0.44-0.88, p = 0.008).

CONCLUSIONS

Satisfaction with the activities that are deemed meaningful is associated with apathy among community-dwelling older adults with MCI.

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

Background

Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.

Objectives

We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.

Design

We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.

Setting

The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.

Participants

People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.

Main outcome measures

The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.

Methods

Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.

Results

Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.

Limitations

Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia.

Conclusions

Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.

Future work

Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.

Study registration

Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

Apathy and agitation in institutionalized older adults: an empirically derived classification

BACKGROUND

Apathy and agitation are often recognized as the most problematic behavioural and psychological symptoms in care settings. In this study, we analyze the relationship between apathy and agitation symptoms other and their relationship with demographic, cognitive, and neuropsychiatric variables and psychotropic medication use.

METHODS

A retrospective study was conducted at a gerontological care centre in Láncara, Spain. Participants were 196 residents of the gerontological care centre, including 143 with a diagnosis of dementia. Apathy and agitation were assessed with the Apathy Scale for Institutionalized Patients with Dementia, Nursing Home version, and the Spanish version of the Cohen-Mansfield Agitation Inventory, respectively. Two-stage hierarchical cluster analysis (hierarchical cluster analysis in a first exploratory stage and K-means clustering to obtain the final solution in the second stage) was conducted to assign residents to different groups based on apathy and agitation scores.

RESULTS

In cluster 1, a certain level of apathy, the highest levels of agitation, and the most frequent intake of atypical antipsychotics and clomethiazole were observed. The highest levels of apathy and the most frequent intake of memantine were seen in cluster 2. The lowest levels of agitation and apathy and the highest levels of cognitive performance were found in cluster 3.

CONCLUSIONS

In this study, subjects with dementia were in a state of high agitation and eventual apathy, had low cognitive status, and were very old. Patients with this profile require well-designed non-pharmacological interventions.

Managing apathy among people with dementia living in institutional settings: Staff's perceived gap between common and best practices

The aim of this study is to explore how staff manage apathy involving a person living with dementia (PLWD). Forty-two staff members working in four Spanish long-term care facilities were interviewed; 21 were nursing assistants and 21 technical staff. They read a vignette about a PLWD presenting apathy. Participants were asked (1) how a situation like that is commonly managed, and (2) how it should be managed. Responses were content-analyzed. Most participants (88.1%) mentioned having experienced a situation similar to the one described in the vignette. Behavior-focused strategies and person-centered strategies were the most frequently mentioned. As for best practices, person-centered strategies emerged as the preferred alternative, and technical staff mentioned them more frequently than assistant carers. Our findings stress the importance of organizational guidelines and staff development in the management of apathy in PLWD.

Pronounced Impairment of Activities of Daily Living in Posterior Cortical Atrophy

INTRODUCTION

The impact of several dementia syndromes on activities of daily living (ADLs) has been well documented, but no study has yet investigated functional ability in posterior cortical atrophy (PCA). The primarily visual nature of deficits in this condition is likely to have a pronounced impact on ADLs.

OBJECTIVE

The aim of this study was to profile functional change in PCA and identify predictors of change.

METHOD

Twenty-nine PCA patients and 25 patients with typical Alzheimer's disease (AD) and their caregivers were included in this cross-sectional study. ADLs were assessed using the Disability Assessment for Dementia (DAD), administered to caregivers, assessing basic ADLs (e.g., eating, dressing) and instrumental ADLs (e.g., managing finances, meal preparation). The predictive utility of cognitive domains (Addenbrooke's Cognitive Examination), behavioural impairment (Cambridge Behavioural Inventory-Revised) and demographic variables on ADL ability was also examined.

RESULTS

PCA patients showed significantly reduced total ADL scores compared to AD patients (medium effect size, d = -0.7; p < 0.05), with significantly more impairment on basic ADLs (large effect size, d = -0.8; p < 0.05) but similar impairment on instrumental ADLs (medium effect size, d = -0.5; p > 0.05). A model combining patient mood, disinhibition, apathy, symptom duration, and memory and attention/orientation scores explained the variance of scores in functional decline (61.2%), but the key factor predicting ADL scores was attention/orientation (p = 0.048).

CONCLUSION

This study shows the profound impact of PCA on ADLs and factors underpinning patients' disability. Attention/orientation deficits were found to correlate and contribute to variance in ADL scores. Future work to develop tailored interventions to manage ADL impairment in PCA should take these findings into account.

Neuroanatomical Abnormalities in Older Depressed Adults With Apathy: A Systematic Review

OBJECTIVE

Apathy is a common phenomenon in late-life depression and is associated with poor outcomes. Apathy is often unrecognized in older depressed adults, and efficacious treatment options are lacking. This review provides a systematic review of the neuroanatomical abnormalities associated with apathy in late-life depression. In addition, the review summarizes the neuroimaging findings from studies of neurodegenerative and focal brain injury conditions that frequently present with apathy. The goal is to elucidate cerebral network abnormalities that give rise to apathy in older adults with mood disturbances and to inform future treatment targets.

METHOD

Systematic literature review.

RESULTS

The few studies that have directly examined the neuroanatomical abnormalities of apathy in late-life depression suggest disturbances in the anterior cingulate cortex, insula, orbital and dorsal prefrontal cortex, striatum, and limbic structures (ie, amygdala, thalamus, and hippocampus). Studies examining the neuroanatomical correlates of apathy in other aging populations are consistent with the pattern observed in late-life depression.

CONCLUSIONS

Apathy in late-life depression appears to be accompanied by neuroanatomical abnormalities in the salience and reward networks. These network findings are consistent with that observed in individuals presenting with apathy in other aging-related conditions. These findings may inform future treatments that target apathy.

The Effectiveness of Non-Pharmacological Interventions on Apathy in Patients With Dementia: A Systematic Review of Systematic Reviews

BACKGROUND

Apathy is one of the behavioral and psychological symptoms of dementia (BPSD), which is the most frequent and can accelerate the progress of dementia.

AIMS

To systematically review the evidence of effectiveness of non-pharmacological interventions on apathy in patients with dementia.

METHODS

Databases including the Cochrane Library, Joanna Briggs Institute (JBI) Library, PubMed, EMBASE, CINAHL, PsycINFO, Psychology and Behavioral Sciences Collection, CNKI, and Wan Fang Data were searched for systematic reviews of the effectiveness of non-pharmacological interventions on apathy in patients with dementia. AMSTAR 2 was applied to assess the methodological quality of reviews.

RESULTS

Nine systematic reviews were included. The average level of overall confidence for included systematic reviews was low. Among all the non-pharmacological interventions involved in this review, the effectiveness of multisensory stimulation, music therapy, cognitive stimulation, and pet therapy was relatively robust. The effects of reminiscence therapy, therapeutic conversation, progressive muscle relaxation, art therapy, exercise therapy, occupational therapy, dementia special care units, nursing staff education, and comprehensive interventions need to be validated further. Meanwhile, the current evidence failed to support the effects of psychomotor therapy and validation therapy on apathy.

LINKING EVIDENCE TO ACTION

Non-pharmacological interventions for apathy in patients with dementia are acceptable. In spite of requirements for adequate and high-quality original studies and quantitative systematic reviews to validate the efficacy of non-pharmacological interventions, multisensory stimulation, music therapy, cognitive stimulation, and pet therapy are deemed the most helpful according to evidences available.

Trained assistance dogs for people with dementia: a systematic review

This systematic review investigated evidence for the effectiveness of trained assistance dogs as an intervention and support for people with dementia. Peer-reviewed articles were retrieved from multiple databases (SCOPUS, Web of Science, and Google Scholar). Reference lists of the articles retrieved were also screened to identify key authors for inclusion. Articles were subject to a quality review, and the results synthesised to address the research questions. Both qualitative and quantitative data were reported. There was evidence of the potential positive effects of dog-assisted interventions in relation to mood, prosocial behaviours, activities of daily living and/or quality of life, cognitive impairment and symptoms specific to dementia, and existential functions. However, the form and quality of the studies varied considerably. It was concluded that further research is needed, particularly for those with younger onset dementia (YOD), for whom there were no specific studies available. Attention needs to be given to establishing adequate-sized samples and designs incorporating control groups. Research would benefit from employing mixed-methods, allowing for the triangulation of qualitative and quantitative data. For deteriorating conditions such as the dementias, studies need to be conducted over time. Furthermore, given the important place family members play in the lives of those with dementia, the effects of dog-assisted interventions on the wider family should also be considered.

Dog-assisted interventions and outcomes for older adults in residential long-term care facilities: A systematic review and meta-analysis

OBJECTIVE

To comprehensively review studies on dog-assisted interventions (DAIs) among older people in residential long-term care facilities (RLTCFs) and to provide an overview of their interventions, outcomes and methodological quality.

METHOD

We searched 18 electronic databases to identify English articles (published January 2000-December 2019) reporting on well-defined DAIs targeting older adults (≥65 years) in RLTCF. Data were extracted by two independent reviewers. Descriptive statistics were produced for quantitative studies, with key themes identified among qualitative studies. Where possible, estimates were pooled from randomised controlled trials using random effects meta-analyses.

RESULTS

Forty-three relevant studies (39 quantitative; 4 qualitative) were identified. The majority of quantitative studies were assessed as low-quality according to the MMAT criteria (n = 26, 67%). Almost half of the quantitative studies (n = 18, 46%) found no significant changes over time or between groups across outcomes measured. The most salient intervention effects included improved social functioning (n = 10), reduced depressive symptoms (n = 6) and loneliness (n = 5). A random-effects meta-analysis revealed a medium effect in favour of DAT on reducing depressive or loneliness symptoms (pooled SMD: 0.66, 95%CI 0.21-1.11; I²  = 50.5; five trials), relative to treatment as usual. However, compared to treatment as usual, no overall effect of DAI on activities of daily living was detected (p = .737). Key themes from qualitative studies included (a) animals as effective transitional objects, (b) the therapeutic value of pets and (c) the significance of the care environment and stakeholders in facilitating DAI.

IMPLICATIONS FOR PRACTICE

The findings of this review indicate that while DAI has value for older people in RLTCF, challenges remain in accurately measuring its impact to provide a stronger evidence-base. Standardisation of DAI service design, delivery and evaluation is required for future research and practice in providing holistic care for older adults.

Effects of a Humanoid Socially Assistive Robot Versus Tablet Training on Psychosocial and Physical Outcomes of Persons With Dementia: Protocol for a Mixed Methods Study

Background

New technologies, like socially assistive robots (SARs), may have the potential to support caregivers at home. Still, the evidence for people with dementia in home care is unclear because a lot of studies are performed in a laboratory or institutional setting, and mainly use robots in prototype stages.

Objective

This study aims to explore the effects of the refined, commercially-available, humanoid SAR Pepper combined with a tablet PC–based dementia training program (Coach Pepper) versus an exclusively tablet PC–based dementia training program on psychosocial and physical outcomes of people with dementia living at home, including caregivers and dementia trainers. We hypothesize that Coach Pepper has a more positive effect on the primary outcome motivation (stable or decreased apathy) of people with dementia.

Methods

A mixed methods study will be performed, including a randomized controlled, parallel, 2-arm study with a complementary qualitative part. This sample includes 40 PWD living at home and 40 relatives, each complemented with five professional caregivers and dementia trainers. The intervention group will receive Coach Pepper (a SAR connected with a tablet PC–based dementia training program), and the control group will receive exclusively tablet PC–based training without the SAR. The duration of the intervention will be three weeks per household. Data will be collected at baseline and during and after the intervention by standardized questionnaires, sensor data of the robot, and tablet PC, as well as semistructured interviews, focus groups, and observation.

Results

To date, no results are available for this study protocol. The study intervention started in May 2019 and will end in Spring 2020.

Conclusions

The intervention of this study can be seen as a nonpharmacological intervention, including cognitive and physical training by a robot. This study will help to further refine SAR for the specific needs of people with dementia living at home.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14927

Addressing Behavioral Symptoms of Dementia Through STAR-VA Implementation: Do Outcomes Vary by Behavior Type?

OBJECTIVES

The STAR-VA program in Veterans Health Administration Community Living Centers (CLCs, nursing home settings) trains teams to implement a psychosocial intervention with residents with behavioral symptoms of dementia (BSD).

METHODS

Across 71 CLCs, 302 residents selected as training cases had target behaviors categorized into one of 5 types: physically aggressive (PA), physically nonaggressive, verbally aggressive, verbally nonaggressive, and behavior deficit (BD).

RESULTS

Across all groups, there were significant declines in team-rated behavior frequency (36%) and severity (44%), agitation (10%), distress behaviors (42%), depression (17%), and anxiety (20%). The magnitude of changes varied across behavior category. For example, those with a PA target behavior experienced a greater percentage decline in agitation and distress behavior scores, and those with a BD target behavior experienced a greater percentage decline in depressive and anxiety symptoms.

CONCLUSIONS

STAR-VA, a multicomponent intervention, is generally effective across various types of behavioral symptoms associated with dementia.

Effectiveness of multisensory stimulation in managing neuropsychiatric symptoms in older adults with major neurocognitive disorder: a systematic review

OBJECTIVE

The objective of the review was to synthesize the effectiveness of multisensory stimulation in managing neuropsychiatric symptoms (NPS) in older adults with major neurocognitive disorder (NCD).

INTRODUCTION

Major neurocognitive disorder is characterized by changes in specific cognitive domains with a progressive deterioration in cognitive ability and capacity for independent living. Most older adults with this condition have one or more concomitant symptoms known as NPS. Evidence shows that nonpharmacological therapies have been effective in controlling these symptoms, with multisensory stimulation attracting further investigation.

INCLUSION CRITERIA

The review considered studies on older adults aged 65 years or over with major NCD. The intervention of interest was multisensory stimulation, and the comparator was usual care (e.g. no occupational therapy, no cognitive training, and no art therapy, but with possible control of activities such as looking at photographs or doing quizzes), or another intervention (e.g. occupational therapy, cognitive training and art therapy). Primary outcomes were NPS (agitation, aggression, motor disturbances, mood liability, anxiety, apathy, night-time behaviour, eating disorders, delusion and hallucination). Secondary outcomes were quality of life, functional status in activities of daily living, cognitive status and caregiver burden. Experimental study designs were considered.

METHODS

A broad range of keywords and a three-step search strategy were used to identify potentially eligible published and unpublished studies from January 1990 to June 2016 in major healthcare-related online databases. Studies in English, Spanish and Portuguese were included. Two independent reviewers assessed the methodological quality of eight included studies using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists for Randomized Controlled Trials and Quasi-Experimental Studies. Data were extracted using the standardized data extraction tool from the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) and included details about the interventions, populations, study methods and outcomes of interest. Significant differences were found between participants, interventions, outcome measures (clinical heterogeneity), and designs (methodological heterogeneity). For these reasons, a meta-analysis could not be performed. Therefore, the results have been described in a narrative format.

RESULTS

Eight studies (seven randomized controlled trials and one quasi-experimental study) were included, with a total sample of 238 participants (pre-intervention). Four studies confirmed the effectiveness of multisensory stimulation in domains such as physically nonaggressive behavior, verbally agitated behavior and agitation. However, these effects did not always persist in the long-term. Six studies showed poorly consistent results on the effects of multisensory stimulation in improving mood, with only one displaying significant effects. Similarly, despite poor results, two studies showed benefits concerning anxiety. Participants reported significantly decreased levels of anxiety over the course of the intervention, and this improvement persisted in the long-term. In regard to functional status in activities of daily living, two studies reported an improvement in the short-term. Moreover, the effectiveness in cognitive domains such as memory and attention to surroundings also showed inconsistent results across the seven studies that analyzed this outcome. Two studies reflected an improvement during the intervention, but also reported a gradual decline in the long-term. Only one study observed significantly better results during the intervention that persisted until the follow-up assessment. Apathy, night-time behavior, eating disorders, delusion and hallucination were NPS that were not explored in the studies that met the criteria to be included in this review.

CONCLUSIONS

These findings suggest that multisensory stimulation could be an effective intervention for managing NPS in older adults with major NCD in a mild to severe stage, particularly for managing behavioral symptoms such as agitation. This research provides an indication of the likely effect of the multisensory stimulation on NPS such as agitation and anxiety, as well on cognitive status.

An intervention to reduce neuropsychiatric symptoms and caregiver burden in dementia: Preliminary results from a randomized trial of the tailored activity program-outpatient version

OBJECTIVE

To evaluate the efficacy of the tailored activity program-outpatient version (TAP-O) and to reduce neuropsychiatric symptoms (NPS) in patients with dementia and caregiver burden compared with a control group (psychoeducation intervention).

METHODS

Twenty-one persons with dementia and their caregivers were recruited and randomized. The intervention group received TAP-O, designed for outpatients with dementia and their caregivers. TAP-O consisted of eight sessions in which an occupational therapist assessed the patient's abilities and interests; prescribed tailored activities; and educated caregivers about dementia, NPS, and how to implement meaningful activities in the daily routine. The control group received eight sessions of a psychoeducation intervention about dementia and NPS.

RESULTS

Compared with controls, patients receiving TAP-O had a significant decrease in hallucination (P = 0.04), agitation (P = 0.03), anxiety (P = 0.02), aggression (P = 0.01), sleep disorder (P = 0.02), aberrant motor behavior (P = 0.02), and in caregiver burden (P = 0.003).

CONCLUSIONS

Findings suggest that TAP-O may be an effective nonpharmacological strategy to reduce NPS of outpatients with dementia and to minimize caregiver burden.

Association between environmental stimulation and apathy in nursing home residents with dementia

OBJECTIVES

Prior research and theories established the link between care environments and apathy. Yet, empirical evidence on how environmental stimulation impacts apathy is lacking. This study examined the association between environmental stimulation and apathy in nursing home residents with dementia.

DESIGN

This repeated-measure study analyzed 104 video observations of staff caregiver-resident interactions.

SETTING

12 nursing homes.

PARTICIPANTS

63 unique staff caregiver-resident dyads that involved 42 caregivers and 44 residents with moderate to severe dementia.

MEASUREMENTS

Second-by-second behavioral coding using Noldus Observer software was conducted to assess apathy and environmental stimulation, using the Person-Environment Apathy Rating scale. The environment subscale includes six items: stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback. The apathy subscale includes six items: facial expression, eye contact, physical engagement, purposeful activity, verbal tone, and verbal expression. Multilevel linear models were used for analysis.

RESULTS

Results showed that apathy was not associated with the overall quality of environmental stimulation but was significantly associated with stimulation specificity (coefficient = -2.23, p = 0.049). However, the association was not significant after controlling for resident characteristics (p = 0.082). In addition, higher levels of environmental feedback were associated with lower apathy levels (coefficient = -2.14, p = 0.001). The association remained significant after controlling for resident characteristics (coefficient = -1.65, p = 0.014).

CONCLUSION

Findings reveal that when environmental stimulation is individually tailored and prompts engagement, residents are less apathetic. This study highlights the effect of environmental stimulation on apathy. Future research should explore interventions that modify environmental stimulation to reduce apathy and improve dementia care.

Collapsin response mediator protein 5 (CRMP5) causes social deficits and accelerates memory loss in an animal model of Alzheimer's disease

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by several behavioral disturbances, especially cognitive decline and deficits in social competence. Previous studies revealed that decreased social activity would accelerate AD progression, whereas enhanced social interaction could rescue AD-induced memory impairment. Collapsin response mediator protein 5 (CRMP5), which belongs to a family of cytosolic proteins, is abundantly expressed in the brain and is involved in the regulation of neurodevelopment and the pathology of several neuropsychiatric diseases. However, the functions of CRMP5 in AD are still unclear. Here, we demonstrated that 9-month-old 3xTg-AD mice exhibited social behavioral deficits and increased hippocampal CRMP5 levels compared to control (B6129S) mice. Knockdown of CRMP5 reversed the social deficits in 9-month-old 3xTg-AD mice, whereas CRMP5 overexpression decreased social interaction in both 3xTg-AD and control mice at 6 months of age. Interestingly, decreased expression of CRMP5 rescued AD-induced memory impairment, but overexpression of CRMP5 accelerated memory loss only in 3xTg-AD mice. In addition, we found that CRMP5 could regulate surface GluA2 and GluA2 S880 phosphorylation. These results suggest that CRMP5 regulates social behavior via modulation of surface GluA2 trafficking and affects memory performance in 3xTg-AD mice.

Review of Programs for Persons Facing Death with Dementia

BACKGROUND

Persons with advanced dementia cannot initiate activities because of the executive dysfunction. The lack of activities was identified as one of the most important factors contributing to behavioral problems of these persons. The unmet needs were boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activities. There is a need for activities designed specifically for residents with advanced dementia.

OBJECTIVE

A description of patient's needs and of programs that intend to maintain quality of life for people with dementia and facing death.

DATA SOURCES

A literature review of programs used for persons with advanced dementia and residing in long-term facilities, using the PubMed data base and collateral sources.

RESULTS

Since palliative care is appropriate for persons with advanced dementia, attention has to be paid to three following important aspects of care: Medical issues, behavioral symptoms, and meaningful activities. Medical interventions should be limited to those which have more benefits than burdens, behavioral symptoms should be distinguished according to the context in which they occur, and treated by non-pharmacological interventions that involve meaningful activities. This review describes four programs that may promote the quality of life in persons with advanced dementia and facing death. They are designed for persons with advanced dementia, taking into account their functional impairments. Most of these programs involve short infrequent sessions. In contrast, Namaste Care is a daily extended program of enhanced nursing care that can provide quality of life until the last breath.

CONCLUSIONS

It is possible to maintain quality life for people with advanced dementia if a special program of activities is available.

The Effect of Reminiscence Therapy With Internet-Based Videos on Cognitive Status and Apathy of Older People With Mild Dementia

This study was carried out to assess the effects of reminiscence therapy that was supported with internet-based videos on the cognitive condition and apathy levels of older people with mild dementia living in nursing homes. This randomized controlled experimental study was conducted between May 15, 2016, and August 25, 2016, in two nursing homes in Adana, Turkey. A total of 32 people participated in this study, 16 individuals were in the intervention group and 16 individuals were in the control group. The data were collected using a Personal Information Form, the Standardized Mini-Mental State Examination (SMMSE) test, and the Apathy Rating Scale (ARS) Self-assessment Form. The individuals in the intervention group received group reminiscence therapy involving internet-based videos for 60 minutes once a week for 3 months. During this period, 25 to 30 minutes of unstructured interviews were carried out with individuals in the control group. The data were analyzed using descriptive statistics, Student t test, the Mann-Whitney U test, and Wilcoxon signed rank test. In this study, a significant difference was found between experimental and control groups' posttest mean scores on the SMMSE test and ARS ( P < .01). The experimental group's SMMSE test and ARS posttest mean scores were higher than those of the control group ( P < .01). This study found that group reminiscence therapy using internet-based videos improved the cognitive functions and apathy levels of older people with mild dementia of the Alzheimer type. It is recommended that group reminiscence therapy studies with Internet-based videos be conducted in care institutions that are responsible for managing older people with mild dementia of the Alzheimer type.

Current treatment of behavioral and cognitive symptoms of Parkinson's disease

Cognitive and behavioral symptoms are common in Parkinson's disease, may occur even in the prodromal stages of the disease, worsen with disease progression, and surpass motor symptoms as the major factors affecting patient quality of life and caregiver burden. The symptoms may be caused by the disease pathology or they may represent adverse effects of treatment, or both etiological factors may contribute. Although many of these symptoms are related to dopaminergic dysfunction or dopaminergic medication, other neurotransmitters are involved as well. Behavioral symptoms including impulse control disorders, apathy, psychosis, as well as mild cognitive impairment and dementia are reviewed with a special focus on current treatment approaches.

Predictors of care dependency in nursing home residents with moderate to severe dementia: A cross-sectional study

BACKGROUND

Nursing home residents with dementia show a rapid decline in their ability to perform activities of daily living. This decline is linked to a greater care dependency, which is associated with a reduced quality of life. Care dependency is influenced by multiple predictors, yet current research often focuses on the contribution of a single or a small number of predictors of care dependency.

OBJECTIVES

To examine the contribution of multiple predictors in predicting care dependency.

DESIGN

The present study analyzed baseline data from a 6-month double-parallel randomized controlled trial which examined the effect of three physical activity interventions on multiple outcomes.

SETTING

This study was conducted in eleven nursing homes in Bergen op Zoom, the Netherlands.

PARTICIPANTS

In total, 85 nursing home residents with moderate to severe dementia were included in the study, of which 75 were included for analysis.

METHODS

Predictors considered were cognitive, physical, neuropsychiatric, demographic, and disease related factors. The outcome measure care dependency was assessed with the Care Dependency Scale and the Erlangen Test of Activities of Daily Living. Linear multilevel regression analyses were used to identify the most important predictors of care dependency.

RESULTS

Apathy, physical endurance, number of comorbidities, and global cognition were significant predictors of care dependency. The model explained 66% of the variance in care dependency. Global cognition was a significant predictor of ability to perform activities of daily living and explained 60% percent of its variance.

CONCLUSION

The present study shows that multiple predictors (i.e., apathy, cognitive and physical abilities, and disease-related factors) contribute to predicting care dependency. Future research could focus on the effectiveness of multifactorial interventions to maintain the highest possible level of independence in nursing home residents with dementia.

Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia

Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.

The effect of errorless learning on psychotic and affective symptoms, as well as aggression and apathy in patients with Korsakoff's syndrome in long-term care facilities

ABSTRACTObjectives:Errorless learning is a promising rehabilitation principle for learning tasks in patients with amnesia, including patients with Korsakoff's syndrome. Errorless learning might possibly also contribute to decreases in behavioral and psychiatric problems, as patients in long-term care facilities become more independent after training. The aim of this study was to examine the effects of errorless learning on potential changes in psychotic and affective symptoms, aggression and apathy, in contrast with a control group who received care as usual.

METHODS

The current study is a quasi-experimental study on errorless learning and psychotic and affective symptoms, aggression, and apathy in patients with Korsakoff's syndrome, living in long-term care facilities for patients with Korsakoff's syndrome (KS) in the Netherlands. The GIP-28, HoNOS-ABI, and NVCL-20 were administered to a group of patients with KS who received errorless learning training (n = 51) and a patient control group who received care as usual (n = 31). Wilcoxon Signed-Rank Tests were performed to examine psychotic and affective symptoms, aggression, and apathy at baseline and at follow-up in the errorless learning group and the control group.

RESULTS

Errorless learning training effectively reduced psychotic symptoms (including provoked confabulations), affective symptoms, and agitation/aggression. There were no significant changes (increases nor decreases) in the control group. Levels of apathy were stable over time in both groups.

CONCLUSIONS

Results with respect to psychotic and affective symptoms, aggression, and apathy are discussed in depth. Patients with KS can become more autonomous in a cared for setting using errorless learning principles. This might also result in decreases in behavioral and psychiatric problems in patients.

Apathy and health-related quality of life in nursing home residents

PURPOSE

To explore the association between apathy and health-related quality of life (HRQoL) from resident and proxy perspectives and whether cognition and depression moderate this relationship.

METHODS

Secondary analyses with baseline data from a cluster randomized trial on the effects of a care program for depression in Nursing Homes (NHs) were conducted. For HRQoL, the Visual Analogue Scale (VAS) and the Dutch version of the European Quality of Life (EQ-5D) were administered to 521 NH residents, and to professional caregivers reporting from the perspective of the NH resident (Resident-Proxy) and from their own perspective (Proxy-Proxy). Utility scores (U) were calculated for the three perspectives. Apathy, depression, and cognition were measured using the 10-item Apathy Evaluation Scale, the Cornell Scale for Depression in Dementia, and the standardized Mini-Mental State Examination, respectively.

RESULTS

Mixed models adjusted for clustering within NH units revealed that apathy was negatively associated with HRQoL both from the Resident-Proxy perspective (EQ-5D VAS: estimated effect, - 0.31, P < 0.001; EQ-5D Utility: - 0.30, P < 0.001) and from the Proxy-Proxy perspective (VAS: - 0.29, P < 0.001; U: - 0.03, P < 0.001), but not from the Resident-Resident perspective (VAS: - 0.05, P = 0.423; Utility: - 0.08, P = 0.161). Controlling for depression and cognition and their interaction terms with apathy did not change the results.

CONCLUSION

Apathy is negatively associated with NH resident HRQoL as reported by proxies. Depression and cognitive functioning do not moderate this association. NH residents do not self-report a relationship between apathy and HRQoL. More research is needed to understand caregiver and NH resident attitudes and underlying assumptions regarding apathy and HRQoL.

Effects of the Namaste Care Family programme on quality of life of nursing home residents with advanced dementia and on family caregiving experiences: study protocol of a cluster-randomised controlled trial

INTRODUCTION

Quality of life of people with advanced dementia living in nursing homes is often suboptimal. Family caregivers can feel frustrated with limited contact with their relatives, which results in visits that are perceived as stressful and not very meaningful. Few psychosocial interventions are specifically developed for people with advanced dementia, and actively involve family caregivers or volunteers. Also, interventions usually stop when it becomes difficult for people to participate. The Namaste Care Family programme aims to increase the quality of life of people with advanced dementia, and improve family caregiving experiences through connecting to people and making them comfortable.

METHODS AND ANALYSIS

Our study will evaluate the effects of the Namaste Care Family programme on quality of life of people with advanced dementia living in nursing homes and family caregiving experiences using a cluster-randomised controlled trial. Longitudinal analyses will be performed taking into account clustering at the nursing home level. Both a cost-effectiveness and a cost-utility analysis from a societal perspective will be performed. We will modify the Namaste Care Family programme to increase family and volunteer involvement in ongoing and end-of-life care. Data collection involves assessments by family caregivers, nursing staff and elderly care physicians using questionnaires, and observations by the researchers at baseline and multiple times over 12 months. The last questionnaire will be sent up to month 24 after the death of the person with dementia. During semistructured interviews, the feasibility, accessibility and sustainability of the Namaste Care Family programme will be assessed.

ETHICS AND DISSEMINATION

The study protocol is approved by the Medical Ethics Review Committee of the VU University Medical Center in Amsterdam (protocol no. 2016.399) and registered with the Nederlands Trial Register (NTR5692). The findings will be disseminated via publications in peer-reviewed journals, conference presentations and presentations for healthcare professionals where appropriate.

TRIAL REGISTRATION NUMBER

NTR5692.

SINTOMAS NEUROPSIQUIÁTRICOS DE IDOSOS COM DEMÊNCIA: REPERCUSSÕES PARA O CUIDADOR FAMILIAR

RESUMO Objetivo: identificar a presença, frequência e gravidade dos sintomas neuropsiquiátricos em idosos com demência, identificar o desgaste do cuidador familiar e analisar os fatores relacionados ao desgaste do cuidador. Método: estudo transversal, descritivo, exploratório e correlacional, realizado com 54 cuidadores familiares de idosos com demência, atendidos em um ambulatório de geriatria de alta dependência de um Hospital Geral Terciário. Utilizaram-se questionário de caracterização dos cuidadores, o Inventário Neuropsiquiátrico e o Inventário Neuropsiquiátrico Desgaste. Resultados: a maioria (85,2%) dos cuidadores familiares era de mulheres, média de idade de 51,2 anos e residia com o idoso (74,1%). A média de sintomas neuropsiquiátricos foi 4,5; o mais presente foi apatia/indiferença (74,1%), seguido de disforia/depressão (46,3%); o mais frequente foi o comportamento motor aberrante (75,1%), seguido de agitação/agressividade (52,9%). Quanto à gravidade dos sintomas, a moderada foi a mais prevalente. Observou-se correlação forte positiva entre o escore total dos questionários aplicados (r=0,82, p=<0,001) e entre o escore total do Inventário Neuropsiquiátrico-Desgaste e o número de sintomas neuropsiquiátricos, apresentados pelos idosos com demência (r=0,83, p=<0,001); correlação fraca positiva entre o escore total do Inventário Neuropsiquiátrico-Desgaste e o número de dias na semana dedicado ao cuidado (r=0,28, p=0,042) e entre problemas de saúde do cuidador e o escore total do Inventário neuropsiquiátrico Desgaste (r=0,29, p=0,034), com significância estatística. Conclusão: os resultados encontrados mostram a necessidade de investimentos na assistência ao binômio idoso/cuidador com vistas ao melhor manejo dos sintomas neuropsiquiátricos e à redução do desgaste do cuidador.