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

Inconsistent Music-Based Intervention Reporting in Dementia Studies: A Systematic Mapping Review

Background

Recent research has shown beneficial results for music-based interventions (MBIs) for persons living with Alzheimer's disease and related dementias (AD/ADRD), but reports often lack sufficient detail about the MBI methodology, which reduces replicability. A detailed checklist for best practices in how to report MBIs was created in 2011 by Robb and colleagues to remedy the lack of detail in MBI descriptions. The implementation of the checklist specifically in AD/ADRD research has not been established. Given the complexity of music and the variety of uses for research and health, specific MBI descriptions are necessary for rigorous replication and validation of study results.

Objective

This systematic mapping review utilized the "Checklist for Reporting Music-Based Interventions" to evaluate the current state of MBI descriptive specificity in AD/ADRD research.

Methods

Research articles testing MBIs and reviews of MBI efficacy published between January 2015 and August 2023 were scored using the checklist and the results were summarized.

Results

Forty-eight studies were screened, and reporting was inconsistent across the 11 checklist criteria. Ten out of 48 studies fully reported more than 5 of the 11 criteria. Only one of the 11 scoring criteria was at least partially reported across 47 of 48 studies.

Conclusions

Thorough reporting of intervention detail for MBIs remains limited in AD/ADRD MBI research. This impedes study validation, replication, and slows the progress of research and potential application of music in practice. Greater implementation of the reporting guidelines provided by Robb and colleagues would move the field of MBI research for AD/ADRD forward more quickly and efficiently.

Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care

BACKGROUND

Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups.

METHODS

This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis.

RESULTS

Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions.

CONCLUSIONS

This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.

Music Intervention for older adults: Evidence Map of Systematic Reviews

BACKGROUND

With the increasing aging population, the health problems of the elderly have received increasing attention. As a non-pharmacological interventions, music intervention has been widely used in clinical practice to improve the physical and mental health of the elderly. This article aims to provide a comprehensive review of existing systematic reviews on the health effects of music interventions for older adults in clinical practice.

METHODS

The study utilized the evidence map methodology, which involved identifying all relevant systematic reviews, meta-analysis from 7 electronic databases from their inception to November 2022. The studies were analyzed using AMSTAR 2.

RESULTS

The researchers identified 67 studies, with the majority published in the past 5 years. The effects of music interventions were categorized into 4 groups of health outcomes: positive (58 results), potentially positive (4 results), inconclusive (2 results), and no effect (3 results). The health outcomes were further classified into 5 groups: psychological well-being, cognitive functioning, physiological responses, quality of life, and overall well-being.

CONCLUSIONS

The study revealed that music interventions for older adults can have positive or potentially positive effects on health outcomes, encompassing psychological well-being, cognitive functioning, physiological responses, quality of life, and overall well-being. However, some studies yielded inconclusive or no effect. The study offers valuable insights for healthcare professionals and serves as a visual resource to access evidence-based information on the use of music interventions in promoting health and addressing various conditions in older adults.

Effects of aromatherapy on agitation in patients with dementia in the community: A quasi-experimental study

The behavioral and psychological symptoms of dementia (BPSD) are experienced by up to 90% of patients with dementia throughout dementia. This study aims to investigate the effect of aromatherapy on agitation in patients with dementia in the community. This prospective cohort study was conducted at a single day-care center for patients with dementia located in northern Taiwan with 2-week and 4-week follow-ups, comparing the severity of agitation between 3 measure points as the primary outcome. The aromatherapy was performed over 5 consecutive days for 4 weeks. Throughout the four-week observation were analyzed by GEE. Significant differences were found in the Chinese version of Cohen-Mansfield Agitation Inventory (CCMAI) total agitation score (ß=-3.622, p=0.037) and physically non-aggressive behavior subscale (ß=-4.005, p=0.004) between aromatherapy group and control group. The severity of dementia-related agitation, especially the severity of physically non-aggressive behavior in demented patients, could be significantly reduced by a four-week intervention of aromatherapy.

An Intervention on Anxiety Symptoms in Moderate Alzheimer's Disease through Virtual Reality: A Feasibility Study and Lessons Learned

(1) Background: Although cognitive impairment is considered the core deficit of dementia, anxiety disorders also have a negative influence on the social and daily life of the affected population. We have explored the exposure of relaxing scenarios in immersive Virtual Reality (iVR) as an intervention strategy for people with moderate Alzheimer's disease. (2) Methods: Three participants were recruited from a day center to participate in a five-week study, which included a Pre- and Post-evaluation with the Montreal Cognitive Assessment (MoCA), Neuropsychiatric Inventory-Questionnaire (NPI-Q), Clinical Dementia Rating Scale (CDR), Global Deterioration Scale (GDS), Hamilton Anxiety Rating Scale (HARS), State-Trait Anxiety Inventory (STAI), and the anxiety subdomain of the Neuropsychiatric Inventory (NPI). Participants' heart rate, oxygen saturation, arterial pressure, and respiratory rate were also monitored during intervention sessions. Three virtual scenarios from Nature Treks VR were used as the intervention over three weeks (a total of nine sessions). (3) Results: Post-intervention anxiety assessment showed a light reduction in psychological anxiety in the HARS questionnaire. A light reduction in heart rate was also observed during the exposure to iVR. (4) Discussion: The use of virtual scenarios was a satisfactory experience for all the participants. Preliminary data point to a relaxing effect of iVR scenarios and a potential reduction in psychological anxiety, but further research is required to confirm the efficacy of the intervention.

Risks and benefits of current and novel drugs to treat agitation in Alzheimer's disease

INTRODUCTION

At present, no pharmacological interventions have been approved for the treatment of agitation in Alzheimer's disease (AD), an important neuropsychiatric symptom that has been linked to increased mortality and greater caregiver burden. Antipsychotics offer some benefit, but increase the risk of adverse events such as falls, extrapyramidal symptoms, stroke, and mortality. Over the past 10 years, several new and repurposed medications have shown promise for treating AD-associated agitation.

AREAS COVERED

We review the risks and benefits of emerging therapies for agitation in AD, which include newer atypical antipsychotics, selective serotonin reuptake inhibitors, cannabinoids, and dextromethorphan combination products. Other drugs such as mirtazapine, prazosin, and lithium are also discussed. Clinicaltrials.gov, PubMed/MEDLINE, EMBASE and Cochrane Central databases were searched for relevant studies from 1 January 2012 to 1 May 2022.

EXPERT OPINION

At the present time, there are no pharmacological interventions for the treatment of agitation in AD whose benefits clearly outweigh their potential safety concerns. Therefore, management of agitation in AD should primarily be based on non-pharmacological approaches. When medications are considered necessary, they should only be initiated with the caregiver's appreciation of their risks and benefits and with careful and ongoing assessment of their safety.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review of Mindfulness-Based Interventions for Patients with Mild Cognitive Impairment or Dementia and Caregivers

The aim of this article was to systematically review the quality and efficacy of the current evidence for mindfulness-based interventions (MBIs) in patients with mild cognitive impairment (MCI), patients with dementia (PwD), and their caregivers. We identified 20 randomized controlled trials (RCTs) (11 for patients, 9 for caregivers) published in the last 15 years. Evidence suggested that MBIs are highly acceptable and credible treatments for patients with MCI, PwD and caregivers. Specifically, for PwD, the results indicated that the magnitude of post-treatment effects of MBIs are in the medium to large range for psychosocial outcomes, and in the small to medium range for cognitive functioning; however, treatment effects on dementia biomarkers were mixed, ranging from small to large, depending on the outcome measure. Findings also evidenced salutary effects of MBIs for caregivers of PwD, with post-treatment effects ranging from medium to large for caregiver stress and burden and large effects for quality of life, and mixed outcomes for cognitive functioning, with effects in the small to large range. However, confidence in these findings is relatively limited due to methodological limitations, especially in terms of poor consistency in intervention strategies, outcome measures, and other key criteria across studies. To better assess the value of MBIs for these populations and optimize treatment outcomes, we recommend further research with improved study methodology (e.g., multi-method assessment, universal criterion and outcome measures, use of active control groups, larger sample sizes, long-term follow-up) to replicate current findings and enhance our understanding of underlying treatment mechanisms of MBIs.

Immediate Beneficial Effect of Makeup Therapy on Behavioral and Psychological Symptoms of Dementia and Facial Appearance Analyzed by Artificial Intelligence Software

BACKGROUND

Possible benefits of makeup therapy, in terms of immediate and late effects on cognitive and affective functions, have not been fully proved for dementia patients.

OBJECTIVE

To evaluate the immediate effect of makeup therapy on dementia patients.

METHODS

Female nursing home residents with dementia received either only skin care treatment (control group, n = 17) or skin care plus makeup therapy treatment (makeup therapy group, n = 19). Cognitive, affective, and activity of daily living (ADL) scores were evaluated before and just after treatments. Apparent age and emotion were also evaluated with artificial intelligence (AI) software.

RESULTS

Makeup therapy significantly improved Abe's behavioral and psychological symptoms of dementia (BPSD) score (ABS, *p < 0.05). AI software judged that makeup therapy significantly made the apparent age younger (*p < 0.05). In particular, patients with moderate ADL scores had a significantly higher happiness score in makeup therapy (*p < 0.05), with a modest correlation to the Mini-Mental State Examination (MMSE, r = 0.42, *p < 0.05). The severe baseline MMSE group reported a greater feeling of satisfaction following makeup therapy (*p < 0.05).

CONCLUSION

The present makeup therapy is a promising non-pharmacological approach to immediately alleviate BPSD in female dementia patients, and the present AI software quickly and quantitatively evaluated the beneficial effects of makeup therapy on facial appearance.

Comprehensive Management of Daily Living Activities, behavioral and Psychological Symptoms, and Cognitive Function in Patients with Alzheimer's Disease: A Chinese Consensus on the Comprehensive Management of Alzheimer's Disease

Alzheimer's disease (AD) is the most common cognitive disorder in the elderly. Its main clinical manifestations are cognitive decline (C), behavioral and psychological symptoms (B), and a decline in the activities of daily living (A), also known as ABC symptoms. Early identification and evaluation of ABC symptoms are helpful for establishing the accurate diagnosis, comprehensive treatment, and prognosis of AD. To guide Chinese clinical practice for optimization of the comprehensive management of AD, in 2018, The Academy of Cognitive Disorder of China gathered 22 neurologists and gerontologists in China to build a consensus on the comprehensive management of AD. Based on a review of the evidence, the consensus summarizes the pathogenesis, pathological changes, clinical manifestations, evaluation, diagnosis, drug and non-drug treatment, and patient care for AD. Focus group discussion was used to establish a flowchart of comprehensive ABC management for AD patients. The new consensus provides a feasible AD management process for clinicians.

AVP-786 as a promising treatment option for Alzheimer's Disease including agitation

INTRODUCTION

To date, there is no FDA-approved treatment for agitation in Alzheimer's disease (AD). Medications currently used off-label have modest clinical efficacy and serious side effects.

AREAS COVERED

The authors review the pharmacology, mechanism of action, pharmacokinetics, efficacy, safety and tolerability data of AVP-786, for the treatment of agitation in AD.

EXPERT OPINION

AVP-786, the deuterated form of dextromethorphan/quinidine (AVP-923) which is an approved treatment for Pseudo-Bulbar Affect, emerges as a promising and safe treatment for agitation in AD. Deuteration is an innovative technology that accelerates drug development by conducting faster and less costly clinical trials. No phase II trial was conducted with AVP-786 for the treatment of agitation in AD; the decision to expedite the development of this drug was based on a successful phase II study with AVP-923. Phase III trials with AVP-786 (TRIAD-1 and TRIAD-2) showed mixed findings probably due to the difference in study design. Future phase III studies should use innovative study designs such as the Sequential Parallel Comparison Design to mitigate high placebo response, and the Cohen-Mansfield Agitation Inventory for agitation assessment. They should also include positron emission tomography studies to assess occupancy of various receptors in the brain after AVP-786 is administered.

Cornel Iridoid Glycoside Suppresses Hyperactivity Phenotype in rTg4510 Mice through Reducing Tau Pathology and Improving Synaptic Dysfunction

rTg4510 mice are transgenic mice expressing P301L mutant tau and have been developed as an animal model of tauopathies including Alzheimer's disease (AD). Besides cognitive impairments, rTg4510 mice also show abnormal hyperactivity behavior. Cornel iridoid glycoside (CIG) is an active ingredient extracted from Cornus officinalis, a traditional Chinese herb. The purpose of the present study was to investigate the effects of CIG on the emotional disorders such as hyperactivity, and related mechanisms. The emotional hyperactivity was detected by locomotor activity test and Y maze test. Immunofluorescent and immunohistochemical analyses were conducted to measure neuron loss and phosphorylated tau. Western blotting was used to detect the expression of related proteins. The results showed that intragastric administration of CIG for 3 months decreased the hyperactivity phenotype, prevented neuronal loss, reduced tau hyperphosphorylation and aggregation in the amygdala of rTg4510 mice. Meanwhile, CIG alleviated the synaptic dysfunction by increasing the expression of N-methyl-D-aspartate receptors (NMDARs) subunits GluN1 and GluN2A and αamino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor (AMPAR) subunits GluA1 and GluA2, and increased the level of phosphorylated Ca²⁺/calmodulin dependent protein kinase II α (p-CaMK IIα) in the brain of rTg4510 mice. In conclusion, CIG may have potential to treat the emotional disorders in tauopathies such as AD through reducing tau pathology and improving synaptic dysfunction.

Introducing virtual reality therapy for inpatients with dementia admitted to an acute care hospital: learnings from a pilot to pave the way to a randomized controlled trial

Background

Behavioural and psychological symptoms of dementia (BPSD) are difficult to manage, particularly in acute care settings. As virtual reality (VR) technology becomes increasingly accessible and affordable, there is growing interest among clinicians to evaluate VR therapy in hospitalized patients, as an alternative to administering antipsychotics/sedatives or using physical restraints associated with negative side effects.

Objectives

Validate and refine the proposed research protocol for a randomized controlled trial (RCT) that evaluates the impact of VR therapy on managing BPSD in acute care hospitals. Special attention was given to ascertain the processes of introducing non-pharmacological interventions in acute care hospitals.

Methods

Ten patients 65 years or older (mean = 87) previously diagnosed with dementia, admitted to an acute care hospital, were recruited over 3-month period into a prospective longitudinal pilot study. The intervention consisted of viewing 20-min of immersive 360° VR using a head-mounted display. Baseline and outcomes data were collected from the hospital electronic medical records, pre/post mood-state questionnaires, Neuropsychiatric Inventory (NPI) score, and standardized qualitative observations. Comprehensive process data and workflow were documented, including timestamps for each study task and detailed notes on personnel requirements and challenges encountered.

Results

Of 516 patients admitted during the study, 67 met the inclusion/exclusion criteria. In total, 234 calls were initiated to substitute decision makers (SDM) of the 67 patients for the consenting process. Nearly half (45.6%) of SDMs declined participation, and 40% could not be reached in time before patients being discharged, resulting in 57 eligible patients not being enrolled. Ten consented participants were enrolled and completed the study. The initial VR session averaged 53.6 min, largely due to the administration of NPI (mean = 19.5 min). Only four participants were able to respond reliably to questions. Seven participants opted for additional VR therapy sessions; of those providing feedback regarding the VR content, they wanted more varied scenery (animals, fields of flowers, holiday themes). Few sessions (4/18) encountered technical difficulties.

Conclusion

The pilot was instrumental in identifying issues and providing recommendations for the RCT. Screening, inclusion criteria, consenting, data collection, and interaction with SDMs and hospital staff were all processes requiring changes and optimizations. Overall, patients with dementia appear to tolerate immersive VR, and with suggested protocol alterations, it is feasible to evaluate this non-pharmacological intervention in acute care hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-020-00708-9.

Application of light therapy in older adults with cognitive impairment: A systematic review

This systematic review aims to assess the efficacy of light therapy on behavioural and psychological symptoms of dementia (BPSD), cognition, functional status, and quality of life in older adults with cognitive impairment; and secondarily, to identify the optimal characteristics of light therapy to establish an adequate protocol for its clinical application. We searched Web of Science and Medline databases through December 2019, resulting in 36 included articles: 3 evaluated the effects on BPSD, 25 on sleep, 12 on agitation, 10 on mood, 4 on neuropsychiatric symptoms, 4 on cognition, 2 on quality of life and 2 on functional status. Literature has shown potential evidence for positive effects of light therapy on managing sleep, behavioural and mood disturbances in people with cognitive impairment, but a limited effect on cognition, quality of life and functional status. This review provides guidelines for intervention protocols with light therapy in older people with cognitive impairment.

Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review

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Most activity interventions for people with dementia in long-term care are facilitated.

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Non-facilitated meaningful activities included music/stimulated family presence, animal-like social robot, lifelike dolls.

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Some beneficial effects for agitation, emotional wellbeing, feelings of pleasure, engagement and sleep quality.

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Future research into the potential benefits of non-facilitated meaningful activities is needed in rigorously designed RCTs.

This systematic review sought to evaluate the effectiveness of non-facilitated meaningful activities for older people with dementia in long-term care facilities. Searches were conducted in PubMed; CINAHL; EMBASE; Web of science; PsycINFO; Cochrane; ProQuest; and ClinicalTrials.gov to identify articles published between January 2004 and October 2019. A total of six studies were included. Results implied that current randomised controlled trials or controlled trials about non-facilitated meaningful activities for people with living dementia in long-term care facilitates are limited, but those included in this review were of adequate methodological quality. Meaningful non-facilitated activities, such as music, stimulated family presence, animal-like social robot PARO/plush toy and lifelike dolls, may have beneficial effects on agitation, emotional well-being, feelings of pleasure, engagement, and sleep quality. However, there remains a lack of conclusive and robust evidence to support these psychological and physiological effects of non-facilitated meaningful activities for older people with dementia living in long-term care facilities by care staff.

Nurses' experiences of providing nonpharmacological pain management in palliative care: A qualitative study

AIM AND OBJECTIVES

To explore the experiences and views of nurses who provide nonpharmacological therapies for chronic pain management in palliative care.

BACKGROUND

Nursing expertise in palliative care is essential in providing pain relief to patients with chronic diseases. Examinations of the use of nonpharmacological therapies for chronic pain management in palliative care have revealed what nonpharmacological therapies have been used, but there is insufficient knowledge regarding nurses' attitudes, views and experiences regarding pain therapies in this context.

DESIGN

A qualitative descriptive design was chosen.

METHODS

Data were collected through individual interviews in a purposive sample with 15 nurses to ensure maximum variation. The data were analysed using qualitative content analysis. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) checklist.

RESULTS

The analysis yielded four categories, as follows: "building and sustaining favourable therapeutic relationships" involved the creation of trust and a solid relationship; in "recognising the diversity of patients' needs," person-centred care is expressed as being vital for individualised nonpharmacological pain management; "incorporating significant others" describes how nurses can help to ease the patient's pain by identifying positive encounters with family members or friends; and in "recognising the existence of barriers," nurses highlight vulnerable groups such as children, for whom nurses require special education to enable optimal nonpharmacological pain management.

CONCLUSION

The unique knowledge that nurses gain about the patient through the nurse-patient relationship is central and crucial for successful nonpharmacological pain management.

RELEVANCE TO CLINICAL PRACTICE

This study emphasises the need for nurses to get to know their patient and to be open and sensitive to patients' descriptions of their unique life situations, as this provides the necessary knowledge for optimal care and pain management. Nurses should be encouraged and given the opportunity to attend specialised training in palliative care and pain management.

[Techniques from EMDR Psychotherapy : a tool against disruptive psycho-behavioural disorders?]

Behavioural disorders in residential care facilities for dependent seniors are particularly common in residents with Alzheimer's and related diseases. Verbal agitation is one of the most disruptive behavioural disorders. The use of techniques from Eye Movement Desensitisation and Reprocessing therapy in gerontology, its applications and research perspectives may be illustrated.

A person-centred team approach targeting agitated and aggressive behaviour amongst nursing home residents with dementia using the Senses Framework

PURPOSE

The increase in agitated or aggressive behaviour amongst nursing home residents with dementia is a challenging problem. Such behaviour causes stress for both resident and caregiver. Many non-pharmacological interventions have been studied, but these interventions disregard the resident's unfulfilled needs and are executed by a single, designated caregiver. This study tests a non-pharmacological intervention, applied by the entire team and based on the resident's underlying needs.

DESIGN

A pretest and post-test interventional study design was used, in which 65 residents with dementia who expressed agitated or aggressive behaviour. Data were collected from December 2016 until March 2017.

METHODS

The ABC method and the Senses Framework were used to assign residents to either therapeutic touch, group music sessions or a meaningful individual activity. All staff members applied the interventions. Data were collected by use of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI).

RESULTS

The frequency of aggression, loss of decorum, depression and the severity of aggression decreased for all three interventions. However, the overall severity of fear also increased. The overall prevalence of agitated of residents decreased for the therapeutic touch, group music sessions and individual activities.

CONCLUSIONS

This study shows the possibilities of designing individualised interventions on the Senses Framework and the ABC method for addressing agitated and aggressive behaviour amongst nursing home residents with dementia. The framework presented in this study should be further explored.

IMPLICATIONS FOR PRACTICE

A team-based approach is effective to reduce agitated or aggressive behaviour amongst nursing home residents.

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.

Effects of Light Treatment on Sleep, Cognition, Mood, and Behavior in Alzheimer's Disease: A Systematic Review

BACKGROUND

Bright light treatment is a therapeutic intervention mainly used to treat sleep and circadian disturbances in Alzheimer's disease (AD) patients. Recently, a handful of studies also focused on the effect on cognition and behavior. Conflicting findings are reported in the literature, and no definite conclusions have been drawn about its specific therapeutic effect.

SUMMARY

The aim of this review is to provide a critical evaluation of available evidence in this field, highlighting the specific characteristics of effective bright light treatment. Eligible studies were required to assess at least one of the following outcome measures: sleep, cognition, mood, and/or behavior (e.g., depression, agitation). A total of 32 articles were included in this systematic review and identified as research intervention studies about light treatment in AD. The quality of the papers was evaluated based on the US Preventive Service Task Force guidelines. Key Messages: Overall, the current literature suggests that the effects of light treatment in AD patients are mixed and may be influenced by several factors, but with a general trend toward a positive effect. Bright light seems to be a promising intervention treatment without significant adverse effects; therefore, further well-designed randomized controlled trials are needed taking into account the highlighted recommendations.

Dementia and Challenging Behaviors in Gerontological Centers. A Case Report

Among the main challenges in geriatric and gerontological centers, we consider, central, the individualized attention to those elderly persons with challenging behaviors, to the extent that it is possible to design preventive strategies that delay cognitive deterioration and minimize consequences of behavior disorders. The first step will be to develop the correct interpretation of symptoms and deficits as a guarantee of a correct diagnosis which, in addition to not always being easy, has to be adapted to the progression of the disease. We present the case of a 68-year-old institutionalized individual, with an initial diagnosis of diffuse Lewy bodies dementia, analyzing his cognitive and behavioral evolution, and the pharmacological and non-pharmacological approach to the case.

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

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

Alzheimer's disease: some pharmacological and non-pharmacological approaches to correcting neuropsychiatric disorders

Today, there is no reliable pharmacological correction of dementia, despite its high prevalence worldwide. The clinical presentation of Alzheimer's disease at one or another stage is accompanied by neuropsychiatric disorders (NPDs) in addition to cognitive defect. The intensity and range of NPDs are different. The possibilities of drug therapy for NPDs are demonstrated. The role of akatinol memantine in correcting a number of psychological and behavioral disorders is highlighted. Biological, psychological, social, and environmental factors are identified among those that contribute to or provoke the development of NPDs. Knowledge of the triggers of mental disorders makes it possible to prevent and thereby reduce or eliminate NPDs. Special emphasis is laid on the patient-caregiver relationship. In recent years, non-pharmacological interventions have been increasingly used as priority-line therapy for NPDs. There are data on main methods for non-pharmacological correction and on the efficiency of their application.

Synthesis and Biological Evaluation of Scutellarein Alkyl Derivatives as Preventing Neurodegenerative Agents with Improved Lipid Soluble Properties

BACKGROUND

Exogenous antioxidants are considered as a promising therapeutic approach to treat neurodegenerative diseases since they could prevent and/or minimize the neuronal damage by oxidation.

OBJECTIVE

Three series of lipophilic compounds structurally based on scutellarein (2), which is one metabolite of scutellarin (1) in vivo, have been designed and synthesized.

METHODS

Their antioxidant activity was evaluated by detecting the 2-thiobarbituric acid reactive substance (TBARS) produced in the ferrous salt/ascorbate-induced autoxidation of lipids, which were present in microsomal membranes of rat hepatocytes. The lipophilicity of these compounds indicated as partition coefficient between n-octanol and buffer was investigated by ultraviolet (UV) spectrophotometer.

RESULTS

This study indicated that compound 5e which had a benzyl group substituted at the C4'- OH position showed a potent antioxidant activity and good lipophilicity.

CONCLUSION

5e could be an effective candidate for preventing or reducing the oxidative status associated with the neurodegenerative processes.

Bright Light Therapy to Treat Depression in Individuals with Mild/Moderate or Severe Dementia

This secondary analysis examined whether the benefits of bright light therapy on depression are greater in persons with mild/moderate or severe dementia. Exploratory analyses were also conducted to determine if bright light treatment targets different depressive symptom clusters based on dementia severity. Analyses using total scores from the instruments, Depressive Symptom Assessment for Older Adults and the Cornell Scale for Depression in Dementia, showed that bright light exposure is an equally effective intervention for depression in persons with both mild/moderate and severe dementia. Analyses of individual depressive subscales revealed that for disagreeable behavior and sleep impairment, bright light therapy appears to have greater benefits in persons with severe dementia than for those with mild/moderate dementia. Overall, this investigation supports the use of bright light therapy to treat depression regardless of dementia severity.

Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia

Background and Objectives

To draw from systematic and other literature reviews to identify, describe, and critique nonpharmacological practices to address behavioral and psychological symptoms of dementia (BPSDs) and provide evidence-based recommendations for dementia care especially useful for potential adopters.

Research Design and Methods

A search of systematic and other literature reviews published from January 2010 through January 2017. Nonpharmacological practices were summarized to describe the overall conceptual basis related to effectiveness, the practice itself, and the size and main conclusions of the evidence base. Each practice was also critically reviewed to determine acceptability, harmful effects, elements of effectiveness, and level of investment required, based on time needed for training/implementation, specialized care provider requirements, and equipment/capital requirements.

Results

Nonpharmacological practices to address BPSDs include sensory practices (aromatherapy, massage, multi-sensory stimulation, bright light therapy), psychosocial practices (validation therapy, reminiscence therapy, music therapy, pet therapy, meaningful activities), and structured care protocols (bathing, mouth care). Most practices are acceptable, have no harmful effects, and require minimal to moderate investment.

Discussion and Implications

Nonpharmacological practices are person-centered, and their selection can be informed by considering the cause and meaning of the individual's behavioral and psychological symptoms. Family caregivers and paid care providers can implement evidence-based practices in home or residential care settings, although some practices require the development of more specific protocols if they are to become widely used in an efficacious manner.

Global perspectives on dementia and art: An international discussion about changing public health policy

In an era of global environmental deterioration and income inequity, public health faces many challenges, including the growing number of individuals, especially older people, with chronic diseases. Dementia is increasingly being seen not just as a biomedical problem to solve but as a public and community challenge to address more broadly. Concepts like prevention, brain health, and quality of life/well-being are receiving more attention. The engagement of community in addressing these challenges is being seen as critical to successful social adaptation. Arts programs are reinvigorating cultural responses to the growing number of older people with cognitive challenges. The humanities offer ways of understanding the power of words and stories in public discourse and a critical lens though which to view political and economic influences. In this paper, we report on a panel held in London on the occasion of the conference at the Royal Society for Public Health in March, 2017, in which the authors presented. Key issues discussed included problem framing, the nature of evidence, the politics of power and influence, and the development of effective interventions. In this paper, we review the rejection of two policies, one on dementia and one on the arts and humanities in public health, by the American Public Health Association; the emergence of policies in the UK; and some of the state of the art practices, particularly in training, again focusing on the UK.

Complementary and Integrative Medicine for Neurologic Conditions

Although many neurologic conditions are common, cures are rare and conventional treatments are often limited. Many patients, therefore, turn to complementary and alternative medicine (CAM). The use of selected, evidence-based CAM therapies for the prevention and treatment of migraine, carpal tunnel syndrome, and dementia are presented. Evidence is growing many of modalities, including nutrition, exercise, mind-body medicine, supplements, and acupuncture.

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.

Music therapy is a potential intervention for cognition of Alzheimer's Disease: a mini-review

Alzheimer's Disease (AD) is a global health issue given the increasing prevalence rate and the limitations of drug effects. As a consequent, non-pharmacological interventions are of importance. Music therapy (MT) is a non-pharmacological way with a long history of use and a fine usability for dementia patients. In this review, we will summarize different techniques, diverse clinical trials, and the mechanisms of MT as it is helpful to the cognition in AD, providing reference for future research. Many articles have demonstrated that MT can reduce cognitive decline especially in autobiographical and episodic memories, psychomotor speed, executive function domains, and global cognition. MT is a promising intervention for strategy of dementia especially of AD and it must be started as early as possible. However, more evidences with prospective, randomized, blinded, uniform and rigorous methodological investigations are needed. And we should consider to combine MT with other cognitive stimulations such as dance, physical exercise, video game, art and so on.

Caregiver's distress related to the patient's neuropsychiatric symptoms as a function of the care-setting

Prevalence of neuropsychiatric symptoms (NPS) and correlation between its intensity and caregiver distress were evaluated as a function of the care-setting in a cross-sectional study including 72 patient-caregiver dyads. The Neuropsychiatric Inventory and the Caregiver Distress Scale were administered. The most prevalent symptoms were: in the formal care-setting, agitation/aggression and depression/dysphoria (42.4%), and in the informal care-setting, aberrant motor behavior (59.0%). While changes in appetite and eating behaviors, depression/dysphoria and irritability/lability were more prevalent in the formal care-setting (p < .0001, p = .011, p = .021), aberrant motor behavior was more prevalent in the informal care-setting (p = .007). NPS were positively correlated with caregiver distress. High patients' scores in hallucinations, sleep and night-time disturbances, anxiety, and aberrant motor behavior were the best predictors of professional caregiver's distress. Agitation/aggression, delusions, disinhibition, apathy/indifference, depression/dysphoria, and elation/euphoria were the best predictors of informal caregiver's distress. Findings may have important clinical implications.

Effect of Bright Light Exposure on Depression and Agitation in Older Adults with Dementia

This study examined the effects of bright light exposure on three measures of depression and four measures of agitation in persons with dementia residing in long-term care. Using a randomized controlled design, participants were randomly assigned to receive either bright light (n = 30) or low intensity light (n = 30) for eight weeks. Bright light exposure was associated with significant improvement in depression and agitation, while participants receiving low intensity light displayed higher levels of depression and agitation or no significant change. Findings support the use of bright light exposure to reduce depression and agitation in this population.