Evidence-Based Guideline

Family Physicians’ Recommendations for the Treatment of Alzheimer’s Disease

The aim of this study was to examine family physicians’ recommendations for various pharmacological and nonpharmacological treatments for Alzheimer’s disease (AD) and its correlates. A phone survey was conducted with 395 family physicians using an experimental vignette methodology, varying in the severity of the disease. Information regarding participants’ recommendations about 10 interventions for the person described in the vignette was elicited. Sociodemographic and professional correlates were examined. Engagement in social activities and participation in support groups were the interventions most recommended by the physicians. Isolation and physical restraints were the least recommended. Recommendations about AD treatments were associated with the severity of the disease and the extent to which the person described in the vignette was perceived as dangerous. Physicians’ recommendations were very similar to those of the lay public, a fact that might contribute to the efficiency of the treatment plan.

"Wish we would have known that!" Communication Breakdown Impedes Person-Centered Care

PURPOSE

To understand how nursing home staff obtain information needed for implementing person-centered care (PCC) to residents with dementia who exhibit behavioral and psychological symptoms of dementia (BPSD), and how they communicate this information to other staff. Barriers to PCC and information exchange were also explored.

DESIGN AND METHODS

Participants were 59 staff from two nursing homes. Focus group methodology captured discussions in eight 1-hr sessions. Sessions were audiotaped and transcribed. Data were analyzed using qualitative content analysis to provide a comprehensive summary of real world context of implementing PCC.

RESULTS

To deliver PCC staff identified a need for access to psychosocial/medical history of the resident and knowledge of strategies families used for managing BPSD in the past. However, resident information is not routinely shared with all staff and written documentation systems for communicating resident-specific information do not support the time-pressured work pattern of certified nursing assistants (CNAs). Word-of-mouth was considered more reliable and expedient than educational sessions. CNAs described themselves as visual learners who prefer educational programs addressing individual resident emergent behaviors and programs that are scheduled at dedicated times.

IMPLICATIONS

To improve PCC the flow of information exchange requires: inclusion of all staff, particularly CNAs; systems of communication that consider the time and resource constraints of nursing homes; development of educational programs for BPSD that are responsive to staff learning styles; administrative investment in nursing leadership to effect these changes; and reimbursement approaches to encourage culture change investments.

Does self-neglect occur among older adults with dementia when unsupervised in assisted living? An exploratory, observational study

The phenomenon of older adults with dementia who develop behavioral expressions when they are unsupervised in assisted living residences is understudied. This qualitative study aimed to bridge this gap in the literature by focusing on 12 residents in various stages of dementia. Grounded Theory was followed to guide data collection and analysis. Data were collected in two special care units of an assisted living residence for 10 months. Participant observation was the primary data collection strategy. Semistructured interviews with staff and managers and review of clinical records augmented the observation data. While unsupervised, residents exhibited a wide spectrum of negative emotional states, behavioral expressions, functional difficulties, wayfinding difficulties, serious hygiene problems, and safety risks. More than half of the identified incidents represented self-neglectful behaviors. The study highlights the need for enhanced supervision and targeted interventions for residents with dementia who are susceptible to self-neglect.

Sundown syndrome in persons with dementia: an update

"Sundowning" in demented individuals, as distinct clinical phenomena, is still open to debate in terms of clear definition, etiology, operationalized parameters, validity of clinical construct, and interventions. In general, sundown syndrome is characterized by the emergence or increment of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in late afternoon, in the evening, or at night. Sundowning is highly prevalent among individuals with dementia. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition. Neurophysiologically, it appears to be mediated by degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin. A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications. To decrease the morbidity from this specific condition, improve patient's well being, lessen caregiver burden, and delay institutionalization, further attention needs to be given to development of clinically operational definition of sundown syndrome and investigations on etiology, risk factors, and effective treatment options.

Ethical and effective: Approaches to residential care for people with dementia

New knowledge underpins calls for change in approaches to the care of people with dementia. Person-centred care is considered essential, whereas purpose-built facilities and environmental design are reported to enhance safety and to have a positive effect on behaviour. Research findings have highlighted the inappropriate use of antipsychotic drugs and there is debate about their value in ‘managing’ symptoms. This paper presents the combination of approaches used to enable residents of two secure dementia units to live life within their ability and without antipsychotic drugs. Essential to the success of the change process was staff education, knowledge of the person, a varied leisure activity programme and a supportive environment. Evidence of the positive difference these strategies made includes statistics that show a decline in falls and behavioural issues, and feedback from family members. In light of the evidence, this article posits that it is ethically wrong to give people with dementia antipsychotic medications because their behaviour is deemed to be unacceptable, when there are other viable options.

Effects of group music intervention on behavioral and psychological symptoms in patients with dementia: a pilot-controlled trial

We investigated the effects of group music intervention on behavioral and psychological symptoms in patients with dementia. Twenty patients were nonrandomly allocated to either a music-intervention group, or an usual care group. The music-intervention group received 50 minutes of music intervention 3 times per week for 5 consecutive weeks. After 15 sessions, the music-intervention group showed significant in improvement with regard to agitation, and the total scores of both patients and caregivers were lower, compared with the control group. These findings suggest that music can improve behavioral and psychological symptoms, especially in patients with dementia and their caregivers.

Chronic Dementing Conditions, Genomics, and New Opportunities for Nursing Interventions

PURPOSE

To (a) provide an overview of chronic dementing conditions; (b) discuss the etiologic and clinical characteristics of Alzheimer disease (AD) and Parkinson disease (PD) within the framework of the family systems genetic illness model; and (c) to explore opportunities to enhance outcomes through the integration of genomics information and technologies into nursing practice.

DESIGN

An integrated review of the literature, including the organizing construct of the family systems genetic illness model.

FINDINGS

AD and PD are both influenced by genetic and environmental factors; in a small percentage of families, gene mutations are the primary etiologic factor. Genetic testing is an option for some families experiencing early-onset, familial disease. Presymptomatic and diagnostic genetic testing have limited clinical utility for the more common late-onset AD and PD.

CONCLUSIONS

The current abilities of healthcare professionals to effectively intervene in people with AD and PD are limited by an incomplete understanding of the biologic basis of these diseases. Advances in genomics research and technology are providing the information and tools necessary to understand the molecular basis of these devastating disorders toward the goal of more specific and effective interventions.