Multisensory Stimulation as an Intervention Strategy for Elderly Patients With Severe Dementia: A Pilot Randomized Controlled Trial

Effects of multisensory environment/stimulation therapy on adults with cognitive impairment and/or special needs: A systematic review and meta-analysis

AIM

This review aimed to evaluate the effects of multisensory environments/stimulation (MSE/MSS) therapy, on the behavior and psychological symptoms in adults with cognitive impairment and/or special needs.

METHODS

Online database searches were performed to identify studies reporting on the effects of MSS/MSE therapy in adults (>18 years). Data were extracted for the following investigated outcomes including anxiety, depression, mood, behavioral attributes, biomedical parameters, cognition, motor skills, quality of life (QoL), pain, and end of life quality. Two reciprocally blinded investigators extracted the data. Inter-investigator reliability (𝝹) was calculated. A meta-analysis and a qualitative analysis were performed on the information extracted.

RESULTS

Thirty-six studies were included for data extraction and analysis. Meta-analysis of the included studies revealed a significant improvement with the MSE/MSS therapy, for agitation (p = .018), anxiety (p = .023), cognition (p < .001), and depression (p < .001). MSS/MSE therapy demonstrated a tendency for the improvement of the QoL in adults (p = .05).

CONCLUSION

MSE/MSS therapies are beneficial in cognitively impaired adults and improve their anxiety, depression, cognitive and other behavioral attributes such as agitative behaviors. Promoting these therapies in geriatric care may help to improve/reduce the challenging/care-resistant behaviors in adults and facilitate effective provision of the necessary care.

Can Virtual Reality Help Improve Motor and Cognitive Function in Active Aging in Older Adults? A Scoping Review

BACKGROUND

Active aging is considered one of the most effective methods for a healthy aging process. There are numerous clinical practice guidelines that address this model and propose multiple strategies for its achievement through the improvement of motor and cognitive function. Virtual reality is emerging as a potential tool, with various modalities focused on promoting good health maintenance in older adults. The objectives of this review were to map the potential benefits of virtual reality for active aging and delve into adaptability and adherence in older individuals.

METHODS

A scoping review was conducted on studies published between 2013 and 2023 in English, Spanish, or Catalan, examining virtual reality interventions in older adults. The search was performed using the Medline, CINAHL, Scopus, and Web of Science databases. The methodological quality was assessed using CASPe and FLC 3.0 critical appraisal guidelines. The graphical data were reported narratively, grouping results based on the study characteristics and the impact of virtual reality.

RESULTS

The review process resulted in the inclusion of 22 articles out of the initial 459 following the application of the selection criteria. Most articles were randomized controlled trials (45.4%; n = 10), systematic reviews (40.9%; n = 9), observational studies (9%; n = 2), and pilot studies (4.5%; n = 1). The information was organized based on the virtual reality modality (immersive, non-immersive, and 360) and application area (motor, cognitive, and mental health).

CONCLUSIONS

Virtual reality (both immersive and non-immersive) is a valuable tool for promoting physical exercise in older adults, helping to prevent recurrent accidental falls. It also yields positive results for cognitive stimulation in healthy older individuals, improving memory, depression, and mental health in those with cognitive impairment. Virtual reality is generally well-received by older adults, achieving high adherence rates.

Are behavioral and psychological symptoms of dementia related to sensory processing?

Problems with sensory processing may have an impact on the behavioral and psychological symptoms that can be seen in Alzheimer's patients. Examining the relationship between the two factors may provide a new perspective for the management of behavioral and psychological symptoms of dementia. Mid-stage Alzheimer's patients completed the Neuropsychiatric Inventory and Adolescent/Adult Sensory Profile. The relationship between behavioral and psychological symptoms of dementia and sensory processing was investigated. Sixty individuals with a mean age of 75.35 (7.86) years and diagnosed with Alzheimer's Dementia 6.6 (2.92) years ago participated in the study. Individuals with severe behavioral and psychological symptoms had higher scores than individuals with moderate behavioral and psychological symptoms in low registration and sensory sensitivity quadrants . A relationship was found between sensory processing and behavioral and psychological symptoms of dementia in mid-stage Alzheimer's patients. This study highlighted the sensory processing differences in patients with Alzheimer's dementia. In future studies, interventions for sensory processing skills may play a role in improving the quality of life of individuals by contributing to the management of behavioral and psychological symptoms of dementia.

Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care

BACKGROUND

People with dementia who are being cared for in long-term care settings are often not engaged in meaningful activities. We wanted to know whether offering them activities which are tailored to their individual interests and preferences could improve their quality of life and reduce agitation. This review updates our earlier review published in 2018.

OBJECTIVES

∙ To assess the effects of personally tailored activities on psychosocial outcomes for people with dementia living in long-term care facilities. ∙ To describe the components of the interventions. ∙ To describe conditions which enhance the effectiveness of personally tailored activities in this setting.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, on 15 June 2022. We also performed additional searches in MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization (WHO) ICTRP, to ensure that the search for the review was as up-to-date and as comprehensive as possible.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials offering personally tailored activities. All interventions included an assessment of the participants' present or past preferences for, or interest in, particular activities as a basis for an individual activity plan. Control groups received either usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of included studies. Our primary efficacy outcomes were agitation and participant quality of life. Where possible, we pooled data across studies using a random effects model.

MAIN RESULTS

We identified three new studies, and therefore included 11 studies with 1071 participants in this review update. The mean age of participants was 78 to 88 years and most had moderate or severe dementia. Ten studies were RCTs (three studies randomised clusters to the study groups, six studies randomised individual participants, and one study randomised matched pairs of participants) and one study was a non-randomised clinical trial. Five studies included a control group receiving usual care, five studies an active control group (activities which were not personally tailored) and one study included both types of control group. The duration of follow-up ranged from 10 days to nine months. In nine studies personally tailored activities were delivered directly to the participants. In one study nursing staff, and in another study family members, were trained to deliver the activities. The selection of activities was based on different theoretical models, but the activities delivered did not vary substantially. We judged the risk of selection bias to be high in five studies, the risk of performance bias to be high in five studies and the risk of detection bias to be high in four studies. We found low-certainty evidence that personally tailored activities may slightly reduce agitation (standardised mean difference -0.26, 95% CI -0.53 to 0.01; I² = 50%; 7 studies, 485 participants). We also found low-certainty evidence from one study that was not included in the meta-analysis, indicating that personally tailored activities may make little or no difference to general restlessness, aggression, uncooperative behaviour, very negative and negative verbal behaviour (180 participants). Two studies investigated quality of life by proxy-rating. We found low-certainty evidence that personally tailored activities may result in little to no difference in quality of life in comparison with usual care or an active control group (MD -0.83, 95% CI -3.97 to 2.30; I² = 51%; 2 studies, 177 participants). Self-rated quality of life was only available for a small number of participants from one study, and there was little or no difference between personally tailored activities and usual care on this outcome (MD 0.26, 95% CI -3.04 to 3.56; 42 participants; low-certainty evidence). Two studies assessed adverse effects, but no adverse effects were observed. We are very uncertain about the effects of personally tailored activities on mood and positive affect. For negative affect we found moderate-certainty evidence that there is probably little to no effect of personally tailored activities compared to usual care or activities which are not personalised (standardised mean difference -0.02, 95% CI -0.19 to 0.14; 6 studies, 632 participants). We were not able to undertake meta-analyses for engagement and sleep-related outcomes, and we are very uncertain whether personally tailored activities have any effect on these outcomes. Two studies that investigated the duration of the effects of personally tailored activities indicated that the intervention effects they found persisted only during the period of delivery of the activities.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia in long-term care may slightly reduce agitation. Personally tailored activities may result in little to no difference in quality of life rated by proxies, but we acknowledge concerns about the validity of proxy ratings of quality of life in severe dementia. Personally tailored activities probably have little or no effect on negative affect, and we are uncertain whether they have any effect on positive affect or mood. There was no evidence that interventions were more likely to be effective if based on one theoretical model rather than another. We included three new studies in this updated review, but two studies were pilot trials and included only a small number of participants. Certainty of evidence was predominately very low or low due to several methodological limitations of and inconsistencies between the included studies. Evidence is still limited, and we remain unable to describe optimal activity programmes. Further research should focus on methods for selecting appropriate and meaningful activities for people in different stages of dementia.

Effectiveness of treatments for people living with severe dementia: A systematic review and meta-analysis of randomised controlled clinical trials

BACKGROUND

Dementia is a progressive neurodegenerative syndrome that has no cure. Although a significant proportion of people with dementia progress into the severe stages of the disease, evidence on the clinical effectiveness of treatments for people with severe dementia remains limited.

AIMS

To systematically review the effectiveness of pharmacological and non-pharmacological treatments for people living with severe dementia and assess the quality of the evidence.

METHOD

We searched MEDLINE, EMBASE, PsycINFO, CINAHL and online clinical trial registers up to January 2022, for Randomised Controlled Trials (RCT) in people living with severe dementia. Quality and risk of bias were assessed independently by two authors.

RESULTS

A total of 30 trials met our inclusion criteria of which 14 evaluated the effectiveness of pharmacological treatments, and 16 evaluated a non-pharmacological intervention. Pharmacological treatments: Meta-analyses indicated that pharmacological treatments (donepezil: 10 mg, 5 mg; galantamine: 24 mg; memantine: 10 mg) are associated with better outcomes compared to placebo for: severity of symptoms (standardized mean difference (SMD) 0.37, 95% CI 0.26-0.48; 4 studies; moderate-certainty evidence), activities of daily living (SMD 0.15, 95% CI 0.04-0.26; 5 studies; moderate-certainty evidence), and clinical impression of change (Relative Risk (RR) 1.34, 95% CI 1.14-1.57; 4 studies; low-certainty evidence). Pharmacological treatments were also more likely to reduce mortality compared to placebo (RR 0.60, 95% CI 0.40-0.89; 6 studies; low-certainty evidence). Non-pharmacological treatments: Five trials were included in the meta-analyses of non-pharmacological interventions (multi-sensory stimulation, needs assessment, and activities-based interventions); results showed that non-pharmacological interventions may reduce neuropsychiatric symptoms of dementia compared to usual care (SMD -0.33, 95% CI -0.59 to -0.06; low certainty evidence).

CONCLUSIONS

There is moderate-certainty evidence that pharmacological treatments may decrease disease severity and improve function for people with severe dementia. Non-pharmacological treatments are probably effective in reducing neuropsychiatric symptoms but the quality of evidence remains low. There is an urgent need for high-quality evidence for other outcomes and for developing service-user informed interventions for this under-served group.

A scoping review: Sensory interventions for older adults living with dementia

This scoping review focused on the existing scholarly literature exploring sensory interventions and immersive environments developed for, and used by, older adults living with dementia. The purpose of the scoping review is 1) to understand the various sensory interventions that have been developed, used, and have provided data to show how such interventions are expected to impact the lives of individuals living with dementia; and 2) to understand how the field is moving forward. We chose to map the literature to understand the types of interventions, the types of outcomes measured, and the contexts of their implementation. Our search was constrained to references from 1990 to 1 June 2019 in the following databases: Academic Search Complete, CINAHL Complete, MEDLINE, PsycINFO databases, and Summon Search discovery layer. We screened 2305 articles based on their titles and abstracts, and 465 were sent to full text review, of which 170 were included in our full text extraction. Once the data were extracted, we created emic categories, which emerged from the data, for data that were amenable to categorization (e.g., study setting, intervention type, and outcome type). We developed ten different categories of interventions: art, aromatics, light, multi-component interventions, multisensory rooms, multisensory, music, nature, touch, and taste. Sensory interventions are a standard psychosocial approach to managing the personal expressions commonly experienced by people living with dementia. Our findings can help providers, caregivers, and researchers better design interventions for those living with dementia, to help them selectively choose interventions for particular outcomes and settings. Two areas emerging in the field are nature interventions (replacing traditional "multisensory rooms" with natural environments that are inherently multisensory and engaging) and multi-component interventions (where cognitive training programs are enhanced by adding sensory components).

Sensory Processing Abnormalities in Community-Dwelling Older Adults with Cognitive Impairment: A Mixed Methods Study

Mild cognitive impairment (MCI) or dementia often leads to behavioral and psychiatric symptoms of dementia (BPSD). Sensory processing abnormalities may be associated with BPSD. The purpose of this study was to explore relationships among sensory processing, behavior, and environmental features within the homes of people with MCI or dementia. This project used mixed methods to assess participants' sensory processing, care partner perspectives on behaviors, and in situ observations of the home environment. Nine participants with cognitive impairment (MCI n = 8, early dementia = 1) and their care partners were included. Seven participants with cognitive impairment were reported to have abnormal sensory processing. Findings suggest that unique environmental adaptations, tailored to personal and sensory preferences for each participant, were associated with a decreased level of behavioral disruption during the observation periods. Implementing sensory-based approaches to maximize environment adaptation may be beneficial in reducing disruptive behaviors for adults with cognitive impairment.

A Novel Intervention for Management of Behavioral and Psychological Symptoms of Dementia in Nursing Home Communal Areas: Results of a Small-Scale Pilot Trial

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) exhibited by persons with dementia (PwD) in nursing home communal areas are generally managed by segregation and/or pharmacological interventions.

OBJECTIVE

This study trialed MindfulGarden (MG), a novel digital calming device, in a Canadian nursing home.

METHODS

Participants were 15 PwD (mean age = 87.67; 5m,10f; mean MMSE = 11.64±7.85). Each was observed by a research assistant (RA) for an average of 8-10 hours on two separate days. The RA followed them during time spent in communal areas of the nursing home including their unit's dining space, lounges, and corridors and spaces shared with other units (e.g., gym and gift shop) and documented any BPSD exhibited. Day-1 provided baseline data; on Day-2, residents were exposed to MG if nursing staff considered their BPSD were sufficiently intense or sustained to warrant intervention. Staff rated the impact as positive, neutral, or negative.

RESULTS

On Day-1, 9 participants exhibited both aggressive and non-aggressive behaviors, 4 non-aggressive behaviors only, and 2 no BPSD. On Day-2, 7 exhibiting aggressive behaviors were exposed to MG. Staff reported MG as having distracting/calming effects and gave positive impact ratings to 6/13 exposures; there were no negative ratings. The most common aggressive BPSD on days of observation were pushing/shoving and screaming.

CONCLUSION

MG may have value as a "psychiatric crash cart" in de-escalating agitation and aggression in care home settings.

Diagnostic criteria for apathy in neurocognitive disorders

INTRODUCTION

Apathy is common in neurocognitive disorders (NCD) but NCD-specific diagnostic criteria are needed.

METHODS

The International Society for CNS Clinical Trials Methodology Apathy Work Group convened an expert group and sought input from academia, health-care, industry, and regulatory bodies. A modified Delphi methodology was followed, and included an extensive literature review, two surveys, and two meetings at international conferences, culminating in a consensus meeting in 2019.

RESULTS

The final criteria reached consensus with more than 80% agreement on all parts and included: limited to people with NCD; symptoms persistent or frequently recurrent over at least 4 weeks, a change from the patient's usual behavior, and including one of the following: diminished initiative, diminished interest, or diminished emotional expression/responsiveness; causing significant functional impairment and not exclusively explained by other etiologies.

DISCUSSION

These criteria provide a framework for defining apathy as a unique clinical construct in NCD for diagnosis and further research.

Person-Centered Care in Persons Living with Dementia: A Systematic Review and Meta-Analysis

Background and Objectives

The concept of person-centered care has been utilized/adapted to various interventions to enhance health-related outcomes and ensure the quality of care delivered to persons living with dementia. A few systematic reviews have been conducted on the use of person-centered interventions in the context of dementia care, but to date, none have analyzed intervention effect by intervention type and target outcome. This study aimed to review person-centered interventions used in the context of dementia care and examine their effectiveness.

Research Design and Methods

A systematic review and meta-analysis were conducted. We searched through 5 databases for randomized controlled trials that utilized person-centered interventions in persons living with dementia from 1998 to 2019. Study quality was assessed using the National Institute for Health and Clinical Excellence checklist. The outcomes of interest for the meta-analysis were behavioral and psychological symptoms in dementia (BPSD) and cognitive function assessed immediately after the baseline measurement.

Results

In total, 36 studies were systematically reviewed. Intervention types were reminiscence, music, and cognitive therapies, and multisensory stimulation. Thirty studies were included in the meta-analysis. Results showed a moderate effect size for overall intervention, a small one for music therapy, and a moderate one for reminiscence therapy on BPSD and cognitive function.

Discussion and Implications

Generally speaking, person-centered interventions showed immediate intervention effects on reducing BPSD and improving cognitive function, although the effect size and significance of each outcome differed by intervention type. Thus, health care providers should consider person-centered interventions as a vital element in dementia care.

Sensory stimulation programs in dementia: a systematic review of methods and effectiveness

INTRODUCTION

Dementia is characterized by the presence of cognitive decline and can lead to sensory-perceptual alterations, compromising the functionality in activities of daily living. The main objective of this work is to review the characteristics of sensory stimulation programs in dementia and its effectiveness.

AREAS COVERED

Studies were identified through a literature search, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Collaboration Guidelines. Twenty studies were included in this review. The studies used multisensory stimulation at different stages of dementia. The results show a lack of consensus regarding frequency, duration, and number of sessions, as well as the duration of the interventions and assessment instruments used to evaluate the results. Multisensory stimulation, particularly Snoezelen, was the most widely used approach. Vision, hearing, touch, and smell were the most frequently stimulated senses. Most studies comprised pre- and post-intervention assessment, but few studies performed follow-up assessment. The interventions that revealed positive results in dementia were Snoezelen, multisensory environment other than Snoezelen, and Multi-sensory Behavior Therapy.

EXPERT OPINION

This review weakly supports sensory stimulation in dementia, providing useful information for rehabilitation and future investigations.

Non-pharmacological therapeutic strategy options for patients with dementia based on cognitive function-A Bayesian network meta-analysis of randomized controlled trials

Dementia represents one of the most common neurodegenerative disorders in older adults. However, it is still unclear whether non-pharmacological therapies (NPTs) are effective or not and which treatment should be preferred. We applied a series of search strategies to identify eligible randomized controlled trials on 1st October, 2018, investigating the effects of NPTs of dementia in the older persons. Pairwise and network meta-analyses were sequentially performed. A total of 31 trials were included, which enrolled 1895 participants and 7 NPTs. Compared with control group, all the NPTs included were statistically beneficial to cognitive function, and our study indicated Comprehensive Therapy(CT) [the surface under the cumulative ranking curve (SUCRA = 92.42%)] might be the best choice for dementia patients. Our study suggests CT might be the optimal NPT for improving the cognitive function of dementia patients. However, the above conclusions need to be further analyzed.

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.

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.

Multisensory Stimulation and Individualized Music Sessions on Older Adults with Severe Dementia: Effects on Mood, Behavior, and Biomedical Parameters

BACKGROUND

Multisensory stimulation and individualized music have shown to be good in handling the psychological and behavioral symptoms in people with severe dementia.

OBJECTIVE

Explore the effects of two nonpharmacological interventions, multisensory stimulation environment (MSSE) in a Snoezelen room and individualized music sessions, on mood, behavior, and biomedical parameters of institutionalized elderly patients with severe dementia.

METHODS

Randomized trial of 21 patients aged ≥65 years randomly assigned to two groups (MSSE and individualized music). Interventions administered in two-weekly sessions lasted 30 minutes for a period of 12 weeks. Main outcomes were recorded before, during, and at the end of the intervention.

RESULTS

Both groups had immediate positive effects on mood and behavior. Participants were more happy/more content (p < 0.001), talked more spontaneously (p = 0.009), related to people better (p = 0.002), were more attentive to/focused on their environment (p < 0.001), enjoyed themselves (p = 0.003), were less bored/inactive (p = 0.004), and more relaxed/content (p = 0.003). The MSSE group performed a better visual follow-up of the stimuli (p = 0.044), and the music group were more relaxed and happy (p = 0.003). A decrease in heart rate (p = 0.013) and an increase in oxygen saturation (p = 0.011) were observed from before to after interventions in both groups, with no significant differences between them.

CONCLUSIONS

Both interventions seem to be effective at managing mood and behavioral disturbances in the short term and at improving physiological rates, highlighting the efficacy of nonpharmacological treatments in patients with severe dementia.

[Quality of life of nursing home residents with dementia before, during and after playing with a magic table]

The 'Active Cues Magic Table' is a new game concept within nursing home care. It consists of light animations projected on a dining table and responding to movements of the players. The aim of this exploratory, quasi-experimental study was to examine the quality of life of nursing home residents with moderately severe or severe dementia before, during and after playing with this magic table. Quality of life was assessed with the Qualidem and the DS-DAT. Of the 34 nursing home residents included, 62% were female and mean age was 86.5 years (standard deviation 6.2). The Qualidem showed a small to moderate improvement in 'negative affect', 'restless tense behavior' and 'positive self-image' up to the week after playing (p ≤ 0.04). The DS-DAT showed a moderate improvement up to one hour after playing compared to a quarter of an hour before playing (p < 0.001). In conclusion, the quality of life of nursing home residents with moderately severe or severe dementia seems to improve up to the week after playing with the magic table. However, future research is needed to confirm the results of this exploratory study and to examine whether the improvements can truly be ascribed to the magic table.

Generation of a function affect model for residents with advanced dementia

AIMS AND OBJECTIVES

This article presents the generation of a model of care encompassing "function" and "affect" based on findings from a 2011 research project aimed at improving care delivery for people with advanced dementia. Objectives were to provide comprehensive and sustainable care, honouring and respecting the person.

BACKGROUND

Dementia is a debilitating, progressive, and terminal disease with a trajectory ranging from approximately 3 to 16 years, yet attention to end-of-life care, promoting comfort, alleviating suffering, and maximizing quality of life is frequently overlooked for people living in the advanced stages of the disease.

METHODS

The research project from which the model was drawn used a three-phase mixed methods approach at three residential aged care facilities (nursing homes) providing high care in New South Wales, Australia. Thematic analysis was elicited from focus group discussions with staff, family members, and carers of residents.

FINDINGS

Themes describe distinct dimensions of a model of care: "function" (dedication, designation, and deliberation) and "affect" (the personal outcomes revealed in relaxation, stimulation, and transformation).

CONCLUSION

Reframing nursing practice from task and disease orientation to person centred and relationship focused is essential in meeting the complete needs of people with advanced dementia. This transformational model of care may be useful in adapting to other end-of-life care settings.

Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care

BACKGROUND

People with dementia who are being cared for in long-term care settings are often not engaged in meaningful activities. Offering them activities which are tailored to their individual interests and preferences might improve their quality of life and reduce challenging behaviour.

OBJECTIVES

∙ To assess the effects of personally tailored activities on psychosocial outcomes for people with dementia living in long-term care facilities.∙ To describe the components of the interventions.∙ To describe conditions which enhance the effectiveness of personally tailored activities in this setting.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, on 16 June 2017 using the terms: personally tailored OR individualized OR individualised OR individual OR person-centred OR meaningful OR personhood OR involvement OR engagement OR engaging OR identity. We also performed additional searches in MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science (ISI Web of Science), ClinicalTrials.gov, and the World Health Organization (WHO) ICTRP, to ensure that the search for the review was as up to date and as comprehensive as possible.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials offering personally tailored activities. All interventions included an assessment of the participants' present or past preferences for, or interests in, particular activities as a basis for an individual activity plan. Control groups received either usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently checked the articles for inclusion, extracted data and assessed the methodological quality of included studies. For all studies, we assessed the risk of selection bias, performance bias, attrition bias and detection bias. In case of missing information, we contacted the study authors.

MAIN RESULTS

We included eight studies with 957 participants. The mean age of participants in the studies ranged from 78 to 88 years and in seven studies the mean MMSE score was 12 or lower. Seven studies were randomised controlled trials (three individually randomised, parallel group studies, one individually randomised cross-over study and three cluster-randomised trials) and one study was a non-randomised clinical trial. Five studies included a control group receiving usual care, two studies an active control intervention (activities which were not personally tailored) and one study included both an active control and usual care. Personally tailored activities were mainly delivered directly to the participants; in one study the nursing staff were trained to deliver the activities. The selection of activities was based on different theoretical models but the activities did not vary substantially.We found low-quality evidence indicating that personally tailored activities may slightly improve challenging behaviour (standardised mean difference (SMD) -0.21, 95% confidence interval (CI) -0.49 to 0.08; I² = 50%; 6 studies; 439 participants). We also found low-quality evidence from one study that was not included in the meta-analysis, indicating that personally tailored activities may make little or no difference to general restlessness, aggression, uncooperative behaviour, very negative and negative verbal behaviour (180 participants). There was very little evidence related to our other primary outcome of quality of life, which was assessed in only one study. From this study, we found that quality of life rated by proxies was slightly worse in the group receiving personally tailored activities (moderate-quality evidence, mean difference (MD) -1.93, 95% CI -3.63 to -0.23; 139 participants). Self-rated quality of life was only available for a small number of participants, and there was little or no difference between personally tailored activities and usual care on this outcome (low-quality evidence, MD 0.26, 95% CI -3.04 to 3.56; 42 participants). We found low-quality evidence that personally tailored activities may make little or no difference to negative affect (SMD -0.02, 95% CI -0.19 to 0.14; I² = 0%; 6 studies; 589 participants). We found very low quality evidence and are therefore very uncertain whether personally tailored activities have any effect on positive affect (SMD 0.88, 95% CI 0.43 to 1.32; I² = 80%; 6 studies; 498 participants); or mood (SMD -0.02, 95% CI -0.27 to 0.23; I² = 0%; 3 studies; 247 participants). We were not able to undertake a meta-analysis for engagement and the sleep-related outcomes. We found very low quality evidence and are therefore very uncertain whether personally tailored activities improve engagement or sleep-related outcomes (176 and 139 participants, respectively). Two studies that investigated the duration of the effects of personally tailored activities indicated that the intervention effects persisted only during the delivery of the activities. Two studies reported information about adverse effects and no adverse effects were observed.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia in long-term care may slightly improve challenging behaviour. Evidence from one study suggested that it was probably associated with a slight reduction in the quality of life rated by proxies, but may have little or no effect on self-rated quality of life. We acknowledge concerns about the validity of proxy ratings of quality of life in severe dementia. Personally tailored activities may have little or no effect on negative affect and we are uncertain whether they improve positive affect or mood. There was no evidence that interventions were more likely to be effective if based on one specific theoretical model rather than another. Our findings leave us unable to make recommendations about specific activities or the frequency and duration of delivery. Further research should focus on methods for selecting appropriate and meaningful activities for people in different stages of dementia.

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.

Creating objects with 3D printers to stimulate reminiscence in memory loss: A mixed-method feasibility study

OBJECTIVE

The objective of the current project was to determine the feasibility of using 3D printed technology to facilitate reminiscence-related activities for persons with memory loss (PWMLs).

METHODS

A parallel convergent mixed methods design was used. Fifteen PWMLs, 13 family members, and six staff from two residential long-term care facilities participated. Participants were observed and interviewed initially, during a 2-week reminiscence session, and again during a 1-month reminiscence session. Staff participants also completed a 1-month focus group, and staff and family members were administered a 3D printing review checklist at 1-month.

RESULTS

The integrated qualitative and quantitative data strongly suggested that PWMLs enjoyed using the 3D objects, were engaged while doing so and appeared to value the objects due to their personalized nature. The use of 3D printed objects also appeared to encourage family involvement as well as family and staff interactions with PWMLs. Barriers to use included memory impairment and behavioral issues.

CONCLUSIONS

The use of 3D printed objects could provide an easy-to-use, well-received, person-centered approach that augments current reminiscence strategies for PWMLs.

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

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

Comparing the Effects of Multisensory Stimulation and Individualized Music Sessions on Elderly People with Severe Dementia: A Randomized Controlled Trial

The objective of this study was to compare the effects of a multisensory stimulation environment (MSSE) and individualized music sessions on agitation, emotional and cognitive status, and dementia severity in a sample of institutionalized patients with severe dementia. Twenty-two participants with a diagnosis of severe or very severe dementia were randomly assigned to two groups: MSSE and individualized music sessions. Both groups participated in two 30-min weekly sessions over 16 weeks. Outcomes were agitation (Cohen-Mansfield Agitation Inventory, CMAI), mood (Cornell Scale for Depression in Dementia, CSDD), anxiety (Rating Anxiety in Dementia, RAID), cognitive function (Severe Mini-Mental State Examination, SMMSE), and the overall severity of dementia (Bedford Alzheimer Nursing Severity Scale, BANS-S). They were assessed at baseline (pre-trial), in the middle (mid-trial), at the end of the intervention (post-trial), and 8 weeks after the intervention (follow-up). Patients in the MSSE group showed significant improvement in their RAID and BANS-S scores compared with the individualized music group post- versus pre-trial. With regard to agitation, there was improvement during the intervention in both the MSSE and individualized music groups in the CMAI total score after 16 weeks of intervention, with no significant differences between the groups. The results suggest that MSSE could have better effects on anxiety symptoms and dementia severity in comparison with individualized music sessions in elderly patients with severe dementia.

Pharmacological and Nonpharmacological Treatment for Apathy in Alzheimer Disease : A systematic review across modalities

OBJECTIVE

Apathy is one of the most frequent neuropsychiatric symptoms encountered in Alzheimer disease (AD). Early diagnosis and timely treatment of apathy in AD seem to be of great importance, since apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress.

DESIGN

Within this context, we conducted an extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies that have investigated the effect of pharmacological and nonpharmacological treatments of apathy in AD.

RESULTS

Acetylcholinesterase inhibitors, gingko biloba, methylphenidate, and a variety of nonpharmacological interventions were found to be successful in reducing apathy in patients with AD. Methodological heterogeneity of the studies and the small amount of studies where apathy was a primary outcome measure are limiting factors to evaluate for group effects.

CONCLUSION

Treatment of apathy in AD is a complicated and an underexplored field. Standardized and systematic efforts primarily focused on the study of apathy in AD may establish a benefit from individualized treatment for specific disease groups that would stem from a combination of both pharmacological and nonpharmacological interventions.

Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities

Due to issues related to informed research consent, older adults with cognitive impairments are often excluded from high-quality studies that are not directly related to cognitive impairment, which has led to a dearth of evidence for this population. The challenges to including cognitively impaired older adults in research and the implications of their exclusion are a transdisciplinary issue. The ethical challenges and logistical barriers to conducting research with cognitively impaired older adults are addressed from the perspectives of three different fields-social work, emergency medicine, and orthopaedic surgery. Issues related to funding, study design, intervention components, and outcomes are discussed through the unique experiences of three different providers. A fourth perspective-medical research ethics-provides alternatives to exclusion when conducting research with cognitively impaired older adults such as timing, corrective feedback and plain language, and capacity assessment and proxy appointments. Given the increasing aging population and the lack of evidence on cognitively impaired older adults, it is critical that researchers, funders, and institutional review boards not be dissuaded from including this population in research studies.

Optimal nonpharmacological management of agitation in Alzheimer's disease: challenges and solutions

Many patients with Alzheimer's disease will develop agitation at later stages of the disease, which constitutes one of the most challenging and distressing aspects of dementia. Recently, nonpharmacological therapies have become increasingly popular and have been proven to be effective in managing the behavioral symptoms (including agitation) that are common in the middle or later stages of dementia. These therapies seem to be a good alternative to pharmacological treatment to avoid unpleasant side effects. We present a systematic review of randomized controlled trials (RCTs) focused on the nonpharmacological management of agitation in Alzheimer's disease (AD) patients aged 65 years and above. Of the 754 studies found, eight met the inclusion criteria. This review suggests that music therapy is optimal for the management of agitation in institutionalized patients with moderately severe and severe AD, particularly when the intervention includes individualized and interactive music. Bright light therapy has little and possibly no clinically significant effects with respect to observational ratings of agitation but decreases caregiver ratings of physical and verbal agitation. Therapeutic touch is effective for reducing physical nonaggressive behaviors but is not superior to simulated therapeutic touch or usual care for reducing physically aggressive and verbally agitated behaviors. Melissa oil aromatherapy and behavioral management techniques are not superior to placebo or pharmacological therapies for managing agitation in AD. Further research in clinical trials is required to confirm the effectiveness and long-term effects of nonpharmacological interventions for managing agitation in AD. These types of studies may lead to the development of future intervention protocols to improve the well-being and daily functioning of these patients, thereby avoiding residential care placement.