Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease

Interventions to improve mood and/or social interaction in residents of long-term care facilities with dementia: A systematic review

OBJECTIVE

To review the available evidence on non-pharmacological interventions to improve mood, quality-of-life (QoL)or social interactions in residents of long-term care facilities with dementia.

METHODS

We searched Medline, Emcare, and PsycINFO using keywords: dementia, long-term care, mood, QoL, and social interaction. The search included long-term care residents clinically diagnosed with dementia and the methodological strength was evaluated using predefined criteria and tools.

RESULTS

The final synthesis included 50 published studies with significant heterogeneity. There was more evidence for green therapy, small-scale living, Snoezelen, Storytelling, group exercise, reminiscence and Montessori activities. However, there was minimal evidence for dementia café, music, recreation time, art activities, staff wearing street-clothes, play activities, humour, traditional food, emotion oriented, simulated presence, computer, wellbeing-enhancing occupation, MultiTANDEM Plus, multisensory, person-centred, animal assisted and Staff Training interventions.

CONCLUSION

Multiple non-pharmacological interventions showed promise in enhancing mood, QoL, and social interaction. Future research could explore long-term effects of therapy, increase sample size of patients, and improve generalizability of therapy.

Towards a Non-pharmacological Intervention on Apathy in Korsakoff's Syndrome: A Systematic Narrative Review Across Different Clinical Conditions

Abstract

Apathy is a quantitative reduction of goal-directed activity, which can be observed in relation to behavior, cognition, emotions and social interaction. It is an invalidating behavioral symptom that is frequently present across different psychiatric conditions and neurocognitive disorders including Korsakoff's Syndrome (KS). In fact, apathy is one of the most severe behavioral symptoms of KS and has a major impact on the lives of patients and their relatives and other informal caregivers. However, guidelines for the treatment of apathy in KS are currently not available. This systematic narrative review provides a transdiagnostic overview of the effectiveness of different types of non-pharmacological interventions on apathy across different study populations that at symptom-level share characteristics with KS. This evidence may inform the development of an intervention targeting apathy in KS. The included study populations are dementia (due to Alzheimer's disease, or vascular dementia), Parkinson's disease, schizophrenia and traumatic brain injury. Through a stepped selection approach and with regard to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 22 systematic reviews and 32 empirical articles on the non-pharmacological treatment of apathy were identified. The results show a variety of effective non-pharmacological interventions on apathy. In conditions with severe cognitive impairments, successful interventions did not rely on intrinsic motivation, self-monitoring, or illness insight of the patients, but depend on external stimulation and behavioral activation. Since apathy is a multidimensional construct, identification of the extent and type of apathetic behavior before starting an intervention is highly recommended. Furthermore, it is important to adjust the treatment to the patients' personal interests and needs and embedded in daily care.

Trial registration

CRD42022298464 (PROSPERO).

Quality of life measurement tools for people with dementia and intellectual disabilities: A systematic review

BACKGROUND

Adults with intellectual disabilities are an at-risk group of developing dementia. In the absence of a cure for dementia, emphasis on treatment is the promotion of Quality of life (QoL). The aim of this review is to identify and describe QoL tools for people with intellectual disabilities and dementia.

METHOD

A systematic review was carried out using 10 databases and papers from up to March year 2021.

RESULTS

Two instruments were identified and examined. The QoL in late-stage dementia, which showed evidence of good levels of internal consistency, intra-rater reliability, test-retest reliability, and convergent validity. The Dementia Quality of Life - proxy was also used; however, its psychometric properties have yet to be studied within the intellectual disabilities population.

CONCLUSION

It is recommended instruments should be developed and psychometrically tested specifically for adults with intellectual disabilities and dementia to help inform policy makers, measure outcomes of interventions and personal outcomes.

From Digital Health to Digital Well-being: Systematic Scoping Review

BACKGROUND

Digital health refers to the proper use of technology for improving the health and well-being of people and enhancing the care of patients through the intelligent processing of clinical and genetic data. Despite increasing interest in well-being in both health care and technology, there is no clear understanding of what constitutes well-being, which leads to uncertainty in how to create well-being through digital health. In an effort to clarify this uncertainty, Brey developed a framework to define problems in technology for well-being using the following four categories: epistemological problem, scope problem, specification problem, and aggregation problem.

OBJECTIVE

This systematic scoping review aims to gain insights into how to define and address well-being in digital health.

METHODS

We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Papers were identified from 6 databases and included if they addressed the design or evaluation of digital health and reported the enhancement of patient well-being as their purpose. These papers were divided into design and evaluation papers. We studied how the 4 problems in technology for well-being are considered per paper.

RESULTS

A total of 117 studies were eligible for analysis (n=46, 39.3% design papers and n=71, 60.7% evaluation papers). For the epistemological problem, the thematic analysis resulted in various definitions of well-being, which were grouped into the following seven values: healthy body, functional me, healthy mind, happy me, social me, self-managing me, and external conditions. Design papers mostly considered well-being as healthy body and self-managing me, whereas evaluation papers considered the values of healthy mind and happy me. Users were rarely involved in defining well-being. For the scope problem, patients with chronic care needs were commonly considered as the main users. Design papers also regularly involved other users, such as caregivers and relatives. These users were often not involved in evaluation papers. For the specification problem, most design and evaluation papers focused on the provision of care support through a digital platform. Design papers used numerous design methods, whereas evaluation papers mostly considered pre-post measurements and randomized controlled trials. For the aggregation problem, value conflicts were rarely described.

CONCLUSIONS

Current practice has found pragmatic ways of circumventing or dealing with the problems of digital health for well-being. Major differences exist between the design and evaluation of digital health, particularly regarding their conceptualization of well-being and the types of users studied. In addition, we found that current methodologies for designing and evaluating digital health can be improved. For optimal digital health for well-being, multidisciplinary collaborations that move beyond the common dichotomy of design and evaluation are needed.

Social Health among German Nursing Home Residents with Dementia during the COVID-19 Pandemic, and the Role of Technology to Promote Social Participation

The COVID-19 pandemic severely impacted the social health of nursing home residents with dementia due to social isolation. Consequently, the frequency of Behavioral and Psychological Symptoms in Dementia (BPSD) might increase. Technological solutions might help safeguard the social health of nursing home residents with dementia. This study investigates the impacts of the COVID-19 pandemic on clinical outcomes and the availability of social activities and technology to promote social participation in nursing home residents with dementia. The study analyzed cross-sectional data from a follow-up questionnaire nested in a larger national survey of care facilities in Germany. A mixed-methods approach integrated statistical analyses of closed-ended responses and thematic analysis of free-text responses. A total of 417 valid individual responses were received, showing an overall increase in observed BPSD-with anxiety and depression most frequently occurring. Many nursing homes canceled all social activities for residents with dementia, though a few had established procedures to facilitate social participation using technology. Requirements to promote social participation in this population using technology were identified at the micro-, meso-, and macro levels. Technology requirements permeated all three levels. During and beyond the COVID-19 pandemic, technology-driven solutions to promote social health among nursing home residents with dementia should be integrated into caregiving procedures.

The Rationale and Design of Behavioral Interventions for Management of Agitation in Dementia in a Multi-Site Clinical Trial

BACKGROUND

Agitation and aggression are common in patients with Alzheimer's disease and related dementias and pose a significant burden on patients, caregivers, and the healthcare systems. Guidelines recommend personalized behavioral interventions as the first-line treatment; however, these interventions are often underutilized. The Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study (ClinicalTrials.gov Identifier # NCT0367220) is a multisite randomized controlled trial comparing an Integrated Care Pathway, that includes a sequential pharmacological algorithm and structured behavioral interventions, with treatment-as-usual to treat agitation in dementia in long-term care and inpatient settings.

OBJECTIVE

To describe the rationale and design of structured behavioral interventions in the StaN study.

METHODS

Structured behavioral interventions are designed and implemented based on the following considerations: 1) personalization, 2) evidence base, 3) dose and duration, 4) measurement-based care, and 5) environmental factors and feasibility.

RESULTS

The process to design behavioral interventions for each individual starts with a comprehensive assessment, followed by personalized, evidence-based interventions delivered in a standardized manner with ongoing monitoring of global clinical status. Measurement-based care is used to tailor the interventions and to integrate them with pharmacotherapy.

CONCLUSION

Individualized behavioral interventions in patients with dementia may be challenging to design and implement. Here we describe a process to design and implement individualized and structured behavioral interventions in the context of a multisite trial in long-term care and inpatient settings. This process can inform the design of behavioral interventions in future trials and in clinical settings for the treatment of agitation in dementia.

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.

La présence simulée comme outil de gestion des troubles du comportement pour les résidents atteints de démence en institution : recommandations

En milieu institutionnel, les troubles du comportement des résidents atteints de démence restent essentiellement abordés via des approches pharmacologiques alors que de nombreuses solutions non médicamenteuses existent. Parmi celles-ci, la présence simulée consiste en un enregistrement sonore ou vidéo réalisé par des proches dans le but d’apaiser un résident présentant un trouble du comportement. La présence simulée est encore peu reconnue du fait, notamment, d’un manque d’information théorique et pratique. Le but de cet article est de proposer des recommandations pratiques et méthodologiques quant à la mise en place et à l’utilisation de la présence simulée. Ces recommandations se basent, d’une part, sur la littérature scientifique et, d’autre part, sur notre propre expérience clinique d’application de cet outil en institution pour résidents atteints de démence.

Simulated presence therapy for dementia

BACKGROUND

Dementia is a common and serious neuropsychiatric syndrome, characterised by progressive cognitive and functional decline. The majority of people with dementia develop behavioural disturbances, also known as behavioural and psychological symptoms of dementia (BPSD). Several non-pharmacological interventions have been evaluated to treat BPSD in people with dementia. Simulated presence therapy (SPT), an intervention that uses video or audiotape recordings of family members played to the person with dementia, is a possible approach to treat BPSD.

OBJECTIVES

To assess the effects of SPT on behavioural and psychological symptoms and quality of life in people with dementia.

SEARCH METHODS

We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), CENTRAL (The Cochrane Library) (9 April 2020), MEDLINE Ovid SP (1946 to 9 April 2020), Embase Ovid SP (1972 to 9 April 2020), PsycINFO Ovid SP (1806 to 9 April 2020), CINAHL via EBSCOhost (1980 to 9 April 2020), LILACS via BIREME (all dates to 9 April 2020), ClinicalTrials.gov (ClinicalTrials.gov) (all dates to 9 April 2020), and the World Health Organization (WHO) Portal (apps.who.int/trialsearch) (all dates to 9 April 2020). We also checked the reference lists of relevant articles to identify any additional studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials, including cross-over studies, that evaluated the efficacy of SPT, consisting of personalised audio or videotape recordings of family members, in people with any form of dementia.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias and extracted data. No meta-analyses were conducted because of substantial heterogeneity among the included studies.

MAIN RESULTS

Three trials with 144 participants met the inclusion criteria. Two of the trials had a randomised cross-over design, one was a cross-over trial which we classified as quasi-randomised. Participants in the included studies were people with dementia living in nursing homes. They were predominantly women and had a mean age of over 80 years. SPT was performed using an audio or video recording prepared by family members or surrogates. It varied in its content, frequency of administration and duration. All the studies compared multiple treatments. In one study, SPT was compared with two other interventions; in the other two studies, it was compared with three other interventions. Specifically, SPT was compared to usual care, personalised music (two studies), a 'placebo' audiotape containing the voice of a person (two studies), and one-to-one social interaction performed by trained research assistants (one study). In terms of outcomes evaluated, one study considered agitation and withdrawn behaviour (both assessed with three methods); the second study evaluated verbal disruptive behaviour (assessed with three methods); and the third study evaluated physically agitated behaviour and verbally agitated behaviour (the method used was not clearly described). According to the GRADE criteria, the overall quality of the evidence was very low due to very small numbers of participants and risk of bias in the included studies; (none of the trials was at low risk of selection bias; all the trials were at high risk of performance bias; one trial was at high risk of attrition bias; and all had unclear selective reporting). Because of variation in the participants, the format of SPT, the comparison interventions, and the measures used to assess outcomes, we judged the results unsuitable for a meta-analysis. Within each trial, the effect of SPT on behaviour, compared to usual care, was mixed and depended on the measure used. Two trials which included a personalised music intervention reported no significant differences between simulated presence and music on behavioural outcomes. Because the overall quality of the evidence was very low, we were very uncertain regarding all the results None of the studies evaluated quality of life or any of our secondary outcome measures (performance of activities of daily living, dropout and carer burden).

AUTHORS' CONCLUSIONS

We were unable to draw any conclusions about the efficacy of SPT for treating behavioural and psychological symptoms and improving quality of life of people with dementia. New high-quality studies are needed to investigate the effect of SPT.

Validation of the Cohen-Mansfield Agitation Inventory Observational (CMAI-O) tool

OBJECTIVES

Behaviours associated with agitation are common in people living with dementia. The Cohen-Mansfield Agitation Inventory (CMAI) is a 29-item scale widely used to assess agitation completed by a proxy (family carer or staff member). However, proxy informants introduce possible reporting bias when blinding to the treatment arm is not possible, and potential accuracy issues due to irregular contact between the proxy and the person with dementia over the reporting period. An observational measure completed by a blinded researcher may address these issues, but no agitation measures with comparable items exist.

DESIGN

Development and validation of an observational version of the CMAI (CMAI-O), to assess its validity as an alternative or complementary measure of agitation.

SETTING

Fifty care homes in England.

PARTICIPANTS

Residents (N = 726) with dementia.

MEASUREMENTS

Two observational measures (CMAI-O and PAS) were completed by an independent researcher. Measures of agitation, functional status, and neuropsychiatric symptoms were completed with staff proxies.

RESULTS

The CMAI-O showed adequate internal consistency (α = .61), criterion validity with the PAS (r = .79, p = < .001), incremental validity in predicting quality of life beyond the Functional Assessment Staging of Alzheimer's disease (β = 1.83, p < .001 at baseline) and discriminant validity from the Neuropsychiatric Inventory Apathy subscale (r = .004, p = .902).

CONCLUSIONS

The CMAI-O is a promising research tool for independently measuring agitation in people with dementia in care homes. Its use alongside the CMAI could provide a more robust understanding of agitation amongst residents with dementia.

The Hyperactivity-Impulsivity-Irritiability-Disinhibition-Aggression-Agitation Domain in Alzheimer's Disease: Current Management and Future Directions

Behavioral and psychological symptoms of dementia (BPSD) afflict the vast majority of patients with dementia, especially those with Alzheimer's disease (AD). In clinical settings, patients with BPSD most often do not present with just one symptom. Rather, clusters of symptoms commonly co-occur and can, thus, be grouped into behavioral domains that may ultimately be the result of disruptions in overarching neural circuits. One major BPSD domain routinely identified across patients with AD is the hyperactivity-impulsivity-irritiability-disinhibition-aggression-agitation (HIDA) domain. The HIDA domain represents one of the most difficult sets of symptoms to manage in AD and accounts for much of the burden for caregivers and hospital staff. Although many studies recommend non-pharmacological treatments for HIDA domain symptoms as first-line, they demonstrate little consensus as to what these treatments should be and are often difficult to implement clinically. Certain symptoms within the HIDA domain also do not respond adequately to these treatments, putting patients at risk and necessitating adjunct pharmacological intervention. In this review, we summarize the current literature regarding non-pharmacological and pharmacological interventions for the HIDA domain and provide suggestions for improving treatment. As epigenetic changes due to both aging and AD cause dysfunction in drug-targeted receptors, we propose that HIDA domain treatments could be enhanced by adjunct strategies that modify these epigenetic alterations and, thus, increase efficacy and reduce side effects. To improve the implementation of non-pharmacological approaches in clinical settings, we suggest that issues regarding inadequate resources and guidance for implementation should be addressed. Finally, we propose that increased monitoring of symptom and treatment progression via novel sensor technology and the "DICE" (describe, investigate, create, and evaluate) approach may enhance both pharmacological and non-pharmacological interventions for the HIDA domain.

A systematic review of non-pharmacological treatments for apathy in dementia

OBJECTIVE

Apathy is one of the most frequent neuropsychiatric symptoms encountered in dementia. Early diagnosis and timely treatment of apathy in dementia are crucial because apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress.

DESIGN

Extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies which have investigated the effect of non-pharmacological treatments of apathy in dementia. Quality of the studies was appraised.

RESULTS

A total of 1303 records were identified and 120 full-texts assessed. Forty-three unique studies were reviewed. A variety of interventions were found to be effective in reducing apathy in demented patients, particularly when provided in a multidisciplinary manner. However, quantification of the effect was limited by the marked methodological heterogeneity of the studies and the small number of studies where apathy was the primary outcome measure.

CONCLUSIONS

Treatment of apathy in dementia is a complex and underexplored field. Certain studies suggest promise for a variety of non-pharmacological interventions. Standardized and systematic efforts primarily focusing on apathy may establish a benefit from individualized treatments for specific disease groups.

Treatment of psychosis in elderly people

Psychotic symptoms in elderly people can be seen in a variety of conditions. This article reviews treatment strategies (both pharmacological and non-pharmacological) for such symptoms in schizophrenia and neurodegenerative disorders in this population. Traditionally, antipsychotics have been the most commonly used treatment for psychotic symptoms. Their usefulness in treating schizophrenia, both chronic and late onset, is well established and the atypical antipsychotics, which have a better side-effect profile, are more suitable for elderly people. More recently, there have been increasing concerns about their safety in psychoses due to dementia. The debate about whether an absolute ban on their use is required is still ongoing, but it has highlighted the need for adopting and developing non-pharmacological interventions.

Simulated presence therapy for dementia

BACKGROUND

Dementia is a common and serious neuropsychiatric syndrome, characterised by progressive cognitive and functional decline. The majority of people with dementia develop behavioural disturbances, also known as behavioural and psychological symptoms of dementia (BPSD). Several non-pharmacological interventions have been evaluated to treat BPSD in people with dementia. Simulated presence therapy (SPT), an intervention that uses video or audiotape recordings of family members played to the person with dementia, is a possible approach to treat BPSD.

OBJECTIVES

To assess the effects of SPT on behavioural and psychological symptoms and quality of life in people with dementia.

SEARCH METHODS

We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), CENTRAL (The Cochrane Library) (9 February 2016), MEDLINE Ovid SP (1946 to 6 January 2017), Embase Ovid SP (1972 to 6 January 2017), PsycINFO Ovid SP (1806 to 6 January 2017), CINAHL via EBSCOhost (1980 to 6 January 2017), LILACS via BIREME (all dates to 6 January 2017), ClinicalTrials.gov (ClinicalTrials.gov) (all dates to 6 January 2017), and the World Health Organization (WHO) Portal (apps.who.int/trialsearch) (all dates to 6 January 2017). We also checked the reference lists of relevant articles to identify any additional studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials, including cross-over studies, that evaluated the efficacy of SPT, consisting of personalised audio or videotape recordings of family members, in people with any form of dementia.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias and extracted data. No meta-analyses were conducted because of substantial heterogeneity among the included studies.

MAIN RESULTS

Three trials with 144 participants met the inclusion criteria. Two of the trials had a randomised cross-over design, one was a cross-over trial which we classified as quasi-randomised.Participants in the included studies were people with dementia living in nursing homes. They were predominantly women and had a mean age of over 80 years. SPT was performed using an audio or video recording prepared by family members or surrogates. It varied in its content, frequency of administration and duration. All the studies compared multiple treatments. In one study, SPT was compared with two other interventions; in the other two studies, it was compared with three other interventions. Specifically, SPT was compared to usual care, personalised music (two studies), a 'placebo' audiotape containing the voice of a person (two studies), and one-to-one social interaction performed by trained research assistants (one study). In terms of outcomes evaluated, one study considered agitation and withdrawn behaviour (both assessed with three methods); the second study evaluated verbal disruptive behaviour (assessed with three methods); and the third study evaluated physically agitated behaviour and verbally agitated behaviour (the method used was not clearly described).According to the GRADE criteria, the overall quality of the evidence was very low due to very small numbers of participants and risk of bias in the included studies; (none of the trials was at low risk of selection bias; all the trials were at high risk of performance bias; one trial was at high risk of attrition bias; and all had unclear selective reporting).Because of variation in the participants, the format of SPT, the comparison interventions, and the measures used to assess outcomes, we judged the results unsuitable for a meta-analysis.Within each trial, the effect of SPT on behaviour, compared to usual care, was mixed and depended on the measure used. Two trials which included a personalised music intervention reported no significant differences between simulated presence and music on behavioural outcomes. Because the overall quality of the evidence was very low, we were very uncertain regarding all the resultsNone of the studies evaluated quality of life or any of our secondary outcome measures (performance of activities of daily living, dropout and carer burden).

AUTHORS' CONCLUSIONS

We were unable to draw any conclusions about the efficacy of SPT for treating behavioural and psychological symptoms and improving quality of life of people with dementia. New high-quality studies are needed to investigate the effect of SPT.

Personal message cards: An evaluation of an alternative method of delivering simulated presence therapy

Simulated presence therapy is a technique which utilises a familiar recorded voice to calm and reassure people with dementia who are agitated or anxious. Although simulated presence therapy has shown potential benefits in small-scale studies, practical limitations in making and playing the recordings have restricted its use. An alternative method of delivering a message from an attachment figure is through a personal message card. This was one of seven products used within the Bath Memory Technology Library which was made available free of charge to people affected by dementia and their carers. This paper provides an evaluation of the personal message cards. Although feedback was received on only 10 of the 24 cards that were distributed, for nine people there was evidence that the cards met the goals that had been set either fully or in part, and that people affected by even quite severe levels of dementia could benefit from them.

Ideals Regarding a Good Life for Nursing Home Residents with Dementia: views of professional caregivers

This study investigates what professional caregivers working in nursing homes consider to be a good life for residents suffering from dementia. Ten caregivers were interviewed; special attention was paid to the way in which they deal with conflicting values. Transcripts of the interviews were analysed qualitatively according to the method of grounded theory. The results were compared with those from a similar, earlier study on ideals found in mission statements of nursing homes. The concepts that were mentioned by most interviewed participants as important for a good life were ‘peace and quiet’, ‘going along with subjective experience’ and ‘no enforcement: the way the resident wants it’. A considerable overlap was found between the interviews and the mission statements; however, when compared with the mission statements, the interviews put less emphasis on individuality and on giving meaning, and more on offering residents pleasant activities. When faced with conflicting values, caregivers tend to make pragmatic and more or less intuitive decisions. Although this has its merits, it may be desirable to stimulate conscious reflection regarding conflict between different values.

Simulated presence therapy, attachment and separation amongst people with dementia

This article examines the impact of Simulated Presence Therapy (SPT) on the behaviour of six people with moderate or severe levels of dementia. Twenty-one sessions involving both SPT and a control condition (usual care) were carried out. SPT interventions were associated with lowered levels of both distressed behaviour and efforts to return home.

Effectiveness of Caregiver Interventions on Patient Outcomes in Adults With Dementia or Alzheimer's Disease: A Systematic Review

Objective: We conducted a systematic review to evaluate whether caregiver-involved interventions improve patient outcomes among adults with dementia or Alzheimer's disease. Method: We identified and summarized data from randomized controlled trials enrolling adults with dementia or Alzheimer's disease by searching MEDLINE, PsycINFO, and other sources. Patient outcomes included global quality of life, physical and cognitive functioning, depression/anxiety, symptom control and management, and health care utilization. Results: We identified 31 trials; 20 compared a caregiver intervention with usual care or usual care with promise of intervention at completion of study period. Fifteen compared one caregiver intervention with another individual or caregiver intervention (active control). Compared with usual care or active controls, caregiver-involved interventions had low to insufficient strength of evidence and did not consistently improve patient outcomes. Discussion: Evidence is insufficient to endorse use of most caregiver interventions to improve outcomes for patients with dementia or Alzheimer's disease.

Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials

BACKGROUND

Agitation in dementia is common, persistent and distressing and can lead to care breakdown. Medication is often ineffective and harmful.

AIMS

To systematically review randomised controlled trial evidence regarding non-pharmacological interventions. Method We reviewed 33 studies fitting predetermined criteria, assessed their validity and calculated standardised effect sizes (SES).

RESULTS

Person-centred care, communication skills training and adapted dementia care mapping decreased symptomatic and severe agitation in care homes immediately (SES range 0.3-1.8) and for up to 6 months afterwards (SES range 0.2-2.2). Activities and music therapy by protocol (SES range 0.5-0.6) decreased overall agitation and sensory intervention decreased clinically significant agitation immediately. Aromatherapy and light therapy did not demonstrate efficacy.

CONCLUSIONS

There are evidence-based strategies for care homes. Future interventions should focus on consistent and long-term implementation through staff training. Further research is needed for people living in their own homes.

Outcome Measures for Dementia in the Advanced Stage and at the End of Life

Increasing life span and lack of medication for prevention or treatment of progressive dementias will significantly increase the number of individuals with advanced dementia worldwide. Providing optimal care for them will stretch health care resources and will require evaluation of different treatment strategies. This paper is presenting measures that may be used in this patient population. Evaluation of global goals of palliative care may include measuring quality of life by QUALID scale, comfort by DS-DAT scale, and engagement by MPES scale. Symptom control may be achieved by measuring pain by PAINAD or PACSLAC scales, by evaluating behavioral symptoms and their management (agitation by SOAPD scale, apathy by AES scale and rejection of care by RTC-DAT scale), and by monitoring patients for dyspnea using RDOS scale. Outcomes of palliative care at the end of life may be evaluated by EOLD-CAD scale and by determining family satisfaction with care (EOLD-SWC). Items included in these scales, psychometric properties, and research use of these scales are described. It is hoped that information in this paper will stimulate research interest in this important area.

The Bedford Alzheimer nursing-severity scale to assess dementia severity in advanced dementia: a nonparametric item response analysis and a study of its psychometric characteristics

The Bedford Alzheimer Nursing-Severity Scale (BANS-S) assesses disease severity in patients with advanced Alzheimer's disease. Since Alzheimer is a progressive disease, studying the hierarchy of the items in the scale can be useful to evaluate the progression of the disease. Data from 164 Alzheimer's patients and 186 patients with other dementia were analyzed using the Mokken Scaling Methodology to determine whether respondents can be ordered in the trait dementia severity, and to study whether an ordering between the items exist. The scalability of the scale was evaluated by the H coefficient. Results showed that the BANS-S is a reliable and medium scale (0.4≤H<0.5) for the Alzheimer group. All items with the exception of the item about mobility could be ordered. When later item was eliminated from the scale, the H coefficient decreased indicating that the scalability of the scale in the original form is more accurate than in the shorter version. For the other dementia group, the BANS-S did not fit any of the Mokken Scaling models because the scale was not unidimensional. In this group, a shorter version of the scale without the sleeping cycle item and the mobility item has better reliability and scalability properties than the original scale.

Nonpharmacological management of apathy in dementia: a systematic review

Apathy is one of the most challenging and prevalent behavioral symptoms of dementia. It is associated with increased disability and caregiver frustration as well as reduced quality of life, rehabilitation outcomes and survival after nursing home admission. A literature search to set criteria yielded 56 nonpharmacological intervention studies with outcomes relevant to apathy in dementia. Studies were rated according to quality and categorized into 7 groups: exercise, music, multisensory, animals, special care programming, therapeutic activities and miscellaneous. Despite a lack of methodological rigor, it is apparent that nonpharmacological interventions have the potential to reduce apathy. This review indicates that therapeutic activities, particularly those provided individually, have the best available evidence for effectiveness in dementia. Recommendations are provided for quality research.

Does theatre improve the quality of life of people with dementia?

BACKGROUND

A new communication method, the "Veder method", has recently been developed. Caregivers are trained to apply this method in a group activity ("living-room theatre activity") for people with dementia in which theatrical stimuli are used in combination with proven emotion-oriented care methods. The aim of this exploratory study was to evaluate the added value of the Veder method group activity compared to a regular reminiscence group activity and to investigate whether professional carers can achieve the same effects with the Veder method as professional actors.

METHODS

A quasi-experimental three-group design was used. Experimental group 1 (E1; n = 65) joined a living-room theatre activity offered by trained professional caregivers. Experimental group 2 (E2; n = 31) joined a living-room theatre activity offered by professional actors. The control group (n = 55) received a usual reminiscence group activity. Behavior, mood and aspects of quality of life were measured using standardized observation scales at three points in time: (T1) pretest; (T2) during the intervention and; (T3) post-test, two hours after the intervention.

RESULTS

During the intervention, significant differences were found in favor of the group that was offered a living-room theatre activity by actors (E2) on different aspects of behavior, mood and quality of life. At post-test, people in E2 were more alert compared to the control group. Moreover, they recalled more memories and showed less socially isolated behavior compared to the control group.

CONCLUSION

This exploratory study shows that the Veder method has some clear positive effects on behavior and mood of people with dementia when applied by professional actors.

Non-pharmacological management of behavioural symptoms of dementia

This article describes a 6-month pilot project in which a community mental health team provided a dementia inreach service into 4 care homes in Birmingham, UK. The project included analysis of the impact of the service at the end of the project as well as a literature review of dementia care in care homes, and especially the issue of antipsychotic medication use and non-pharmacological approaches in managing behavioural and psychological symptoms of dementia (BPSD). The project included training care home staff in the management of BPSD; 2 questionnaires distributed at the beginning of the project found that 65% of care home staff felt a need for education and awareness, practical problem-solving and counselling in managing BPSD. Self-reported knowledge of common mental health problems and dementia increased in care home staff at the end of the project by a margin of 7% and 11% respectively. Reported confidence in managing behavioural problems increased by 9% among care home staff at the end of the project. The project achieved regular monitoring of psychotropic medications, and enabled the discharge of 14 out of 63 existing patients in the selected homes. The project also provided guidance for non-pharmacological techniques for management of BPSD, which included relaxation techniques, distraction techniques, reality orientation, reminiscence work, needs led therapy, music therapy, person-centred approach and behaviour therapy.

Managing Agitated Behaviour in People with Alzheimer's Disease: The Role of Live Music

Background:

Agitation due to Alzheimer's disease (AD) presents a challenge to occupational therapists working in the older people care sector. Recently, background music and music therapy have emerged as promising tools in the management of agitation in AD. This exploratory study investigated whether live music could reduce agitated behaviour in people with AD.

Method:

A quasi-experimental one-group repeated measures design investigated the effect of a live, one-to-one, musical violin intervention on agitated behaviour in people with moderate-severe AD in a residential care facility. Seven participants received the musical intervention on three occasions. Participants were video recorded before, during and after each session. Behaviour was assessed by the investigator and a blinded assessor, using an investigator-modified Cohen-Mansfield Agitation Inventory. Thirty agitated behaviours were examined. Data were analysed using the Friedman test.

Results:

This intervention reduced agitated behaviour among participants. Significant reductions in pacing/aimless wandering (p = 0.023), performing repetitious mannerisms (p = 0.036) and general restlessness (p = 0.007) were observed. The total number of agitated behaviours decreased significantly (median 5 [range 2–8] behaviours before the intervention to 1 [range 0–4] during and 1 [range 0–5] after the intervention [p = 0.005]).

Conclusion:

Live music may be an effective strategy to reduce short-term agitated behaviour among people with AD.

The comprehensive process model of engagement

BACKGROUND

Engagement refers to the act of being occupied or involved with an external stimulus. In dementia, engagement is the antithesis of apathy.

OBJECTIVE

The Comprehensive Process Model of Engagement was examined, in which environmental, personal, and stimulus characteristics impact the level of engagement.

METHODS

: Participants were 193 residents of 7 Maryland nursing with a diagnosis of dementia. Stimulus engagement was assessed via the Observational Measure of Engagement, measuring duration, attention, and attitude to the stimulus. Twenty-five stimuli were presented, which were categorized as live human social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli.

RESULTS

All stimuli elicited significantly greater engagement in comparison to the control stimulus. In the multivariate model, music significantly increased engagement duration, whereas all other stimuli significantly increased duration, attention, and attitude. Significant environmental variables in the multivariate model that increased engagement were: use of the long introduction with modeling (relative to minimal introduction), any level of sound (especially moderate sound), and the presence of between 2 and 24 people in the room. Significant personal attributes included Mini-Mental State Examination scores, activities of daily living performance and clarity of speech, which were positively associated with higher engagement scores.

CONCLUSIONS

Results are consistent with the Comprehensive Process Model of Engagement. Personal attributes, environmental factors, and stimulus characteristics all contribute to the level and nature of engagement, with a secondary finding being that exposure to any stimulus elicits engagement in persons with dementia.

Using video simulated presence to reduce resistance to care and increase participation of adults with dementia

BACKGROUND

Cognitive and functional decline in dementia generally impairs performance of basic care activities. Staff assistance during these activities frequently results in confusion, anxiety, and distress, expressed through resistance to care (RTC).

METHODS

A single-system ABA withdrawal design (n = 1) evaluated the effect of video-simulated presence (VSP) for decreasing RTC and increasing participation. A family member pre-recorded videos for use during episodes of RTC, in which the family member spoke directly to the participant to encourage participation.

RESULTS

Introduction of the VSP significantly reduced RTC during the basic care tasks of feeding and talking medication. This effect was reversed when the intervention was withdrawn. Participation increased following VSP, demonstrating clear trends toward clinical significance.

CONCLUSIONS

This person-centered intervention, based on VSP of a family member, provides encouraging results for reducing RTC and increasing participation of adults with dementia in basic care tasks.

Anxiety and related symptoms in older persons with dementia: directions for practice

Anxiety disorders and related symptoms commonly occur in older people with cognitive impairment or dementia, significantly worsening functioning and reducing quality of life. This review of the literature outlines the extent of the problem, and focuses on current best practices in psychosocial interventions anxiety in persons with dementia. Discussion follows on promising nonpharmacological interventions that are recommended for further consideration and future research.

The value of social attributes of stimuli for promoting engagement in persons with dementia

The present study examined the impact of different attributes of social stimuli using the stimulus attributes aspect of the Comprehensive Process Model of Engagement ( Am J Geriatr Psychiatry. 17:299-307). Participants were 193 residents of 7 Maryland nursing homes with a diagnosis of dementia. Stimuli were chosen to represent different levels of the following social attributes: social versus not social, realistic versus not realistic, animated versus nonanimated, human versus nonhuman, and alive versus not alive. Participants had significantly longer engagement, were significantly more attentive, and displayed a significantly more positive attitude with social stimuli than with nonsocial stimuli. Longer durations and higher ratings of attention and attitude were seen with realistic and animated stimuli as compared to their counterparts. Human and live stimuli resulted in significantly more engagement than their counterparts. Giving any social stimulus to the residents is preferable to providing none, and the social attributes of stimuli should be maximized.

Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli?

OBJECTIVES

To assess the relative effect of different types of stimuli on agitated behaviors of nursing home residents with dementia.

DESIGN

Repeated-measures design with randomized assignment of conditions.

SETTING

Seven Maryland nursing homes.

PARTICIPANTS

One hundred eleven nursing home residents with a diagnosis of dementia who exhibited agitation.

INTERVENTION

Different types of stimuli (music, social stimuli, simulated social stimuli, and individualized stimuli based on the person's self-identity) were presented.

MEASUREMENTS

Agitation was directly observed and recorded using the Agitation Behavior Mapping Instrument.

RESULTS

All stimulus categories were associated with significantly less physical agitation than baseline observations, and all except for manipulative stimuli were associated with significantly less total agitation. Live social stimuli were associated with less agitation than music, self-identity, work, simulated social, and manipulative stimulus categories. Task and reading stimulus categories were each associated with significantly less agitation than work, simulated social, and manipulative stimulus categories. Music and self-identity stimuli were associated with less agitation than simulated social and manipulative stimuli.

CONCLUSION

Providing stimuli offers a proactive approach to preventing agitation in persons with dementia, with live social stimuli being the most successful.

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.

Direct observation of behavior: a review of current measures for use with older adults with dementia

This review article reports on methods of direct observation of behaviors for use in long-term care settings, particularly with older adults who have dementia. This article provides information on the theoretical roots, administration methods, and psychometric properties of measures of direct observation of individual behavior. It is hoped that this review will help gerontological nurses make informed choices about the direct observation measures that suit their specific needs, highlight the role of direct observation in quality improvement for dementia care, and facilitate a balance between identifying a gold standard and allowing flexibility to assess project-specific behaviors.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to substantially improve patient-reported and observer-reported outcomes in many clinical conditions, but most reports on effects of placebos are based on studies that have not randomised patients to placebo or no treatment. Two previous versions of this review from 2001 and 2004 found that placebo interventions in general did not have clinically important effects, but that there were possible beneficial effects on patient-reported outcomes, especially pain. Since then several relevant trials have been published.

OBJECTIVES

Our primary aims were to assess the effect of placebo interventions in general across all clinical conditions, and to investigate the effects of placebo interventions on specific clinical conditions. Our secondary aims were to assess whether the effect of placebo treatments differed for patient-reported and observer-reported outcomes, and to explore other reasons for variations in effect.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 4, 2007), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), PsycINFO (1887 to March 2008) and Biological Abstracts (1986 to March 2008). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Trials with binary data were summarised using relative risk (a value of less than 1 indicates a beneficial effect of placebo), and trials with continuous outcomes were summarised using standardised mean difference (a negative value indicates a beneficial effect of placebo).

MAIN RESULTS

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I(2) 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I(2) 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

AUTHORS' CONCLUSIONS

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

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

BACKGROUND

Advanced dementia is characterized by severe cognitive and functional impairments that lead to almost total dependency in self-care. Neuropsychiatric symptoms (NPS) are common in advanced dementia, diminishing quality of life and increasing the care burden. The challenge for health care providers is to find safe and effective treatments. Non-pharmacological interventions offer the potential for safer alternatives to pharmacotherapy, but little is known about their efficacy. This review evaluates the published literature on non-pharmacological interventions for treating NPS in advanced dementia.

METHODS

A literature search was undertaken to find non-pharmacological intervention studies published between 1998 and 2008 that measured NPS outcomes in individuals diagnosed with advanced dementia. Strict inclusion criteria initially required that all study participants have severe or very severe dementia, but this range was later broadened to include moderately severe to very severe stages.

RESULTS

Out of 215 intervention studies, 21 (9.8%) specifically focused on treatments for individuals with moderately severe to very severe dementia. The studies provide limited moderate to high quality evidence for the use of sensory-focused strategies, including aroma, preferred or live music, and multi-sensory stimulation. Emotion-oriented approaches, such as simulated presence may be more effective for individuals with preserved verbal interactive capacity.

CONCLUSIONS

Most studies of interventions for dementia-related NPS have focused on individuals with mild to moderate cognitive impairment. Individuals with severe cognitive impairment do not necessarily respond to NPS treatments in the same manner. Future studies should be specifically designed to further explore the stage-specific efficacy of non-pharmacological therapies for patients with advanced dementia. Areas of particular need for further research include movement-based therapies, hands-on (touch) therapies, and interventions that can be provided during personal care routines. Interventions appear to work best when they are tailored to balance individual arousal patterns.

Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards

OBJECTIVE

To provide a systematic review of selected experimental studies of psychosocial treatments of behavioral disturbances in dementia. Psychosocial treatments are defined here as strategies derived from one of three psychologically oriented paradigms (learning theory, unmet needs and altered stress thresholds).

METHOD

English language reports published or in press by December 2006 were identified by means of database searches, checks of previous reviews and contact with recognized experts. Papers were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another.

RESULTS

Only 25 of 118 relevant studies met every specification. Treatment proved more effective than an attention control condition in reducing behavioral symptoms in only 11 of the 25 studies. Effect sizes were mostly small or moderate. Treatments with moderate or large effect sizes included aromatherapy, ability-focused carer education, bed baths, preferred music and muscle relaxation training.

CONCLUSIONS

Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were mostly small to moderate with a short duration of action. This limited action means that treatments will work best in specific, time-limited situations. In the few studies that addressed within-group differences, there were marked variations in response. Some participants benefited greatly from a treatment, while others did not. Interventions proved more effective when tailored to individuals' preferences.

Psychosocial treatments of psychological symptoms in dementia: a systematic review of reports meeting quality standards

BACKGROUND

This paper provides a systematic review of selected experimental studies of the effectiveness of psychosocial treatments in reducing psychological symptoms in dementia (e.g. anxiety, depression, irritability and social withdrawal).

METHOD

English language reports published or in press by February 2008 were identified by means of database searches and checks of previous reviews. Reports were appraised with respect to study design, participants' characteristics and reporting details. Because people with dementia often respond positively to personal contact, studies were included only if control conditions entailed similar levels of social attention or if one treatment was compared with another.

RESULTS

Only 12 of 48 relevant papers met every specification. Treatments proved more effective in reducing psychological symptoms than an attention control condition or another treatment in only six of the 12 selected studies. Interventions with moderate effect sizes included music and recreation therapy.

CONCLUSIONS

Some psychosocial interventions appear to have specific therapeutic properties, over and above those due to the benefits of participating in a clinical trial. Their effects were generally modest with an unknown duration of action. This limited efficacy suggests that treatments will work best in specific, time-limited situations, tailored to individuals' requirements. There is no preferred method to rate psychological symptoms.

The efficacy of nurse implemented non-pharmacological strategies for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities: a systematic review

AIM

Agitation is a common symptom of dementia which becomes exacerbated in the advanced stages of the disease. The negative effects of this symptom are numerous and often result in institutionalisation. Given it is the registered nurse, with the cooperation of the enrolled nurse/ assistant in nursing, who provide the majority of face-to-face care in residential aged care facilities, there is a clear need to identify effective management strategies for agitated behaviours which nursing staff can easily access and implement.This review identifies the best available evidence regarding the efficacy of nurse implemented non-pharmacological strategies for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities METHOD: A systematic literature search of MEDLINE, CINAHL, PsycINFO, Cochrane Library, SCOPUS, EMBASE, and AgeLine databases was undertaken. Additionally, the reference lists of relevant papers were examined for additional trials.This review considered any English language randomised trial that investigated strategies implemented by a nurse for the symptom management of agitation in persons with advanced dementia living in residential aged care facilities. Outcomes measured included frequency and severity of agitation.

RESULTS

Seven trials were included in this review. Five of the seven strategies investigated were shown to be effective in the symptom management of agitation when compared to alternate strategies. Effective strategies include: behavioural therapy, balancing arousal states, therapeutic touch, multi-sensory stimulation and person-centred bathing.

CONCLUSIONS

The heterogeneity of the included trials made it difficult to draw definitive conclusion. However, the results of this systematic review reveal that some non-pharmacological strategies are effective when implemented by a nurse for the symptom management of agitation in pesons with advanced dementia living in residential aged care facilities. Despite this finding, there is currently insufficient evidence to develop practice guidelines.

Effectiveness of simulated presence therapy for individuals with dementia: a systematic review and meta-analysis

OBJECTIVES

To formally assess the strength of evidence for the efficacy of simulated presence therapy for challenging behaviours in dementia (playing an audio or videotape to an individual, personalized by a carer and containing positive experiences from the client's life and shared memories involving family and friends) using meta-analytic techniques.

METHOD

Systematic review and meta-analysis of k = 4 studies of simulated presence therapy for challenging behaviours in dementia.

RESULTS

Meta-analysis indicated a significance effect (d = 0.70, 95% CI = 0.38-1.02), although this was reduced when the first published study was removed from the analysis.

CONCLUSION

These findings provide limited support for the use of simulated presence therapy with this population and stress the importance of assessing participants' suitability for such an approach and monitoring their responses closely. Future adequately powered studies are necessary to confirm the efficacy of simulated presence therapy.

Technology Studies to Meet the Needs of People With Dementia and Their Caregivers

The aim of this article is to present the findings of a review of studies that focused on technology supporting people with dementia and their caregivers. A literature search was carried out in eight scientific literature databases covering literature published between January 1992 and February 2007. A total of 46 studies providing original data and one review were included in this review. Analyses covered the aims of the studies, the technology used, study design, methods, outcome variables, and results. Most studies were carried out in residential care and focused on the needs of formal caregivers. Only a few studies involved people with dementia actively using the technology. The studies are difficult to compare because of the large variety of aims, technologies, design, and outcome measurements. There is a need for more research in this area, in particular, with people who have a mild stage dementia living in the community.

Prescribing activities that engage passive residents. An innovative method

Individuals with dementia are often passive, which places them at risk for further cognitive and functional decline. Recreational activities have been used in research to reduce passive behaviors, but systematic reviews of these studies have found modest effect sizes for many activities. In this article, we describe the further theoretical development of an innovative method for prescribing activities that have a high likelihood of engaging nursing home residents who are passive and present examples for research application and clinical practice. This method may increase the effect size of activity interventions and encourage more widespread adoption of nonpharmacological interventions in practice.

Alzheimer's disease and related dementias

The number of individuals with Alzheimer's disease or a related dementia is growing at a staggering rate. Thus, it is essential that social workers in geriatric settings are knowledgeable about this disorder and the appropriate interventions to use at all stages of the disease. The purpose of this article is to examine the types of non-pharmacological, psychosocial treatments that are used to manage the behavioral manifestations and changes in the mood of individuals with Alzheimer's disease or a related dementia. While great strides have been made in pharmacological treatments of Alzheimer's disease, less attention has been given to the types of psychosocial interventions that are readily employed in community-based and long-term care settings to assist in the care of these individuals. This article provides an overview of psychosocial interventions, as well as identifies the direction for future evidence-based treatment studies, for individuals with Alzheimer's disease and related dementia.

Nonpharmacological treatment of agitation: a controlled trial of systematic individualized intervention

OBJECTIVE

The objective of this study was to examine the efficacy of a systematic algorithm for providing individualized, nonpharmacological interventions for reducing agitated behaviors in nursing home residents with dementia.

METHODS

This placebo-controlled study combined nomothetic and ideographic methodologies. The study was conducted in 12 nursing home buildings in Maryland; 6 were used as treatment facilities, and 6 as control facilities. Participants were 167 elderly nursing home residents with dementia. Interventions were tailored to the individual profiles of agitated participants using a systematic algorithm that considered type of agitation and unmet needs. Interventions were then designed to fulfill the need in a manner that matched the person's cognitive, physical, and sensory abilities, and their lifelong habits and roles. Interventions were provided for 10 days during the 4 hours of greatest agitation. Direct observations of agitation were recorded by trained research assistants via the Agitated Behavior Mapping Instrument (ABMI). Evaluation of positive and negative affect was also based on direct observation and assessed via Lawton's Modified Behavior Stream. Data analysis was performed via SPSS software.

RESULTS

The implementation of personalized, nonpharmacological interventions resulted in statistically significant decreases in overall agitation in the intervention group relative to the control group from baseline to treatment (F(1,164) = 10.22, p =.002). In addition, implementation of individualized interventions for agitation resulted in statistically significant increases in pleasure and interest (F(1,164) = 24.22, p <.001; F(1,164) = 20.66, p <.001).

CONCLUSIONS

The findings support the use of individualized nonpharmacological interventions to treat agitation in persons with dementia and underscore the importance for clinicians of searching for underlying reasons for agitated behaviors.

A comparison of two treatments of agitated behavior in nursing home residents with dementia: simulated family presence and preferred music

OBJECTIVE

The objective of this study was to compare the effectiveness of two individualized psychosocial treatments in reducing the frequency of physically and verbally agitated behaviors in nursing home residents whose dementia was complicated by marked behavioral disturbance.

METHODS

Thirty nursing home residents with frequent, severe behavioral disturbances were observed by research staff before, during, and after multiple, randomized, single-blind exposures to 15-minute audiotapes of simulated family presence (a conversation prepared by a family member about positive experiences from the past), music preferred by the resident in earlier life, and a placebo condition of a reading from a horticultural text. Selected (usually multiple) physical and verbal behaviors were counted as present or absent at regular intervals. All three treatment conditions were compared with usual care.

RESULTS

Simulated presence and preferred music both proved effective in reducing counts of physically agitated behaviors. Simulated presence, but not music, resulted in significantly reduced counts of verbally agitated behaviors. The placebo tape proved more effective than expected. Participants' responses to simulated presence and music varied widely. Behavior counts fell by one-half or more in many cases. Other residents became more agitated.

CONCLUSION

Participants' better-than-expected responses to the placebo tape suggest that even the simplest technology can improve the lives of confused, disturbed nursing home residents. Of the two psychosocial treatments, preferred music tapes were easier to make and were clearly helpful in many instances. By contrast, family members often struggled to recall enough happy memories to compile a simulated presence tape. Simulated presence might prove just as effective if relatives speak on topics of their own choosing. Although not all residents were helped by these treatments, adverse effects were mild and shortlived.

Difficult behaviors in long-term care patients with dementia

Difficult behaviors are relatively common challenges that can occur throughout the natural progression of dementia, but are particularly common in the mid to late stages of disease. These behaviors can be challenging to manage in nursing and assisted care facilities, and can cause distress to the caregivers and to the patients themselves. Our ability to manage these symptoms can have a profound effect on the patient's quality of life. This article reviews the appropriate assessment of behavioral and psychological symptoms of dementia (BPSD) and the literature supporting various nonpharmacologic and pharmacologic treatments. Nonpharmacologic approaches should be the initial focus for treatment of most BPSD, but should these prove inadequate, a variety of medications are available with varying degrees of clinical research to support their use in ameliorating BPSD.