High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis

Yeh, S-W et al. (2020) |High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis |Clinical Rehabilitation | https://doi.org/10.1177/0269215520961637

This systematic review underlines the impact of high intensity exercise on older people with dementia. The researchers reviewed some 15 articles describing six trials including older adults and controlled groups. They report that facilitated activities had an effect on of daily living and psychiatric well-being; with effects on activities of daily living being the most long-lasting. This review also highlights how adverse effects of high-intensity functional exercise were minimal to none.

Abstract

Objective:

This study aimed to investigate the efficacy of high-intensity functional exercise among older adults with dementia.

Methods:

In this systematic review and meta-analysis of randomized controlled trials, we collected articles published before August 2020 from PubMed, Embase, and the Cochrane Library to evaluate the effect of high-intensity functional exercise on older adults with dementia. Primary outcomes included improvements in balance function and gait performance (speed, cadence, and stride length). The secondary outcomes included lower limb strength, activities of daily living, psychiatric well-being, depression, and cognition. Furthermore, we performed subgroup analysis with two high-intensity functional exercise programs: the Umeå program and Hauer’s program.

High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis – Shu-Wei Yeh, Li-Fong Lin, Hung-Chou Chen, Li-Kai Huang, Chaur-Jong Hu, Ka-Wai Tam, Yi-Chun Kuan, Chien-Hsiung Hong, 2020

Results:

We identified 15 articles describing six trials including older adults with dementia undergoing high-intensity functional exercise or control activity. The meta-analysis indicated that high-intensity functional exercise, both in Hauer’s program and in the Umeå program, significantly improved balance function (pooled standardized mean difference 0.57, 95% confidence interval 0.31–0.83). Hauer’s program significantly improved gait speed, cadence, stride length, and lower limb strength. Beneficial effects on speed, cadence, and lower limb strength were retained for several months. The Umeå program facilitated activities of daily living and psychiatric well-being, with effects on activities of daily living lasting several months. In the only eligible trial, no effects on cognition were observed. Adverse effects of high-intensity functional exercise were minimal to none.

Conclusions:

High-intensity functional exercise is generally safe and is recommended for older individuals with mild or moderate dementia to provide benefits in motor performance and daily functioning (Source: Yeh, S-W et al., 2020).

Rotherham NHS staff can request this article from the Library

NIHR: Informal dementia carers had to make difficult decisions about paid care during COVID-19

NIHR | January 2021 | Informal dementia carers had to make difficult decisions about paid care during COVID-19

Often people in the community living with dementia rely on informal, unpaid carers such as family and friends. Researchers wanted to find out how the first nationwide COVID-19 lockdown affected unpaid carers, and how they made decisions about accessing paid care. They conducted telephone interviews with 15 unpaid carers during the first wave of the pandemic (April and May 2020 ). From this sample almost three quarters (73.3%) of the carers lived with the person they were caring for. A little over half (53.3%) of carers were caring for their spouse.

Now this, the first study to report on the impact of COVID-19 on paid home care for people living with dementia, highlights how unpaid carers had to increase their care hours, but also areas of concern and difficult decisions carers had to make.

The researchers drew three themes from the interviews:

  • Carers felt concerned by the risk of paid carers bringing coronavirus into the home. Lack of personal protective equipment (PPE) and feeling unprepared to provide additional care heightened these fears: “I didn’t know how to use all the equipment and I didn’t feel safe and also didn’t know how to protect myself from injury and well and being of risk to Mum”.
  • Carers had difficult choices to make. Many avoided hospitals and other health providers. They struggled to weigh up the options of cancelling or continuing paid care and some described real fears of re-obtaining paid care post-COVID if they cancelled during lockdown.: “..a family friend of ours who’s already been told by their social worker that because they’ve managed without the [paid] care then they’re not likely to get it back after the coronavirus”.
  • Implications for unpaid carers included increased workload and difficulty in accessing food deliveries: “At the moment I can’t get an online shopping slot. Trying to get through to the helpline to get us put on the vulnerable list has proved an impossibility, I’ve spent hours and hours and hours on the phone which gives you a layer of angst that on top of everything else you don’t need”.

Lead author Clarissa Giebel, Research Fellow, Department of Primary Care & Mental Health, University of Liverpool & NIHR ARC NWC

When we did these interviews in April, most family carers were so afraid of the virus that they cancelled paid care, even though they desperately needed it. As a result, they got overburdened. I’ve spoken to people as part of a new study who said they got so burnt out during COVID that they had to send their loved one to a care home. We need to remember those carers are people in their own right and they need psychological support and care support too.

Clarissa Giebel, Research Fellow, Department of Primary Care & Mental Health, University of Liverpool

Read the full NIHR Evidence update Informal dementia carers had to make difficult decisions about paid care during COVID-19

Primary paper available from BMC Geriatrics

SCIE: Safeguarding adults with dementia during the COVID-19 pandemic

Social Care Institute for Excellence| updated 5 January 2021| Safeguarding adults with dementia during the COVID-19 pandemic

Social Care Institute for Excellence in partnership with the Alzheimer’s Society has published a quick guide to support care providers and staff to safeguard people with dementia during the pandemic. There are increased concerns that, during this time, people may be more vulnerable to abuse or neglect.

This may be a result of:

The guide is available online from SCIE

NIHR Alert: Careful phrasing of requests by hospital staff could help people with dementia accept care

NIHR | December 2020 | Careful phrasing of requests by hospital staff could help people with dementia accept care

“Healthcare professionals in acute hospitals are not generally trained in how to communicate with people with dementia. This has an impact on their job satisfaction and stress levels. People with dementia and their relatives also report dissatisfaction with communication in hospital.”

Rebecca O’Brien, Study Author, Clinical Researcher School of Health Sciences/ Division of Rehab, Ageing and Well-being University of Nottingham
This study intended to provide healthcare professionals with ways to communicate more effectively with people living with dementia (PLWD). The authors analysed video recordings of HCPs and PWDs interactions from three inpatient wards. Their analysis led to a recognition of requests which led to patients agreement or refusal
The experts also recognise that no manner of verbal requesting would guarantee compliance or ultimately override a patient’s right to refuse to comply with a request. They identify several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. This indicates that by varying tone, phrasing and question construction led to a more positive response from patients who were confused or resisting care.

The authors want to equip health professionals with the skills to make requests in different ways. O’Brien also wants “policymakers to understand the importance of the need to train staff in communication skills.” (Source: NIHR and O’Brien et al, 2020)

O’Brien, R., Beeke, s., Pilnick, A. & Harwood, R.H. | 2020| When people living with dementia say ‘no’: Negotiating refusal in the acute hospital setting | Social Science and Medicine | Vol. 263 113188

Abstract

A quarter of UK acute hospital beds are occupied by people living with dementia (PLWD). Concerns have been raised by both policy makers and carers about the quality of communication between hospital staff and PLWD. PLWD may experience communication impairments such as word finding difficulties, limited ability to construct coherent narratives and difficulties understanding others. Since much healthcare delivery occurs through talk, healthcare professionals (HCPs) and PLWD are likely to experience increased communication barriers. Consistent with this, HCPs report stress and reduced job satisfaction associated with difficulty communicating with PLWD. HCPs face these challenges whilst striving to deliver person-centred care, respecting the autonomy and wishes of the patient before them. However, best practice recommendations in the field tend not to be based on actual interactional evidence. This paper investigates recurring interactional difficulties around HCP requests to carry out health and social care tasks and subsequent reluctance or refusal on the part of PLWD. Using conversation analysis, we examined 41 video recordings of HCP/PLWD interactions collected across three acute inpatient wards. We identify both the nature of the refusals, and any mitigation offered, and explore the requests preceding them in terms of entitlement and contingency. We also explore the nature of HCP requests which precede PLWD agreement with a course of action. We conclude that several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. Our findings underline the importance of examining the contextual interactional detail involved in the negotiation of healthcare, which here leads to an understanding of how design of HCP requests can impact on an important healthcare activity being carried out. They also emphasise the power of conversation analytic methods to identify areas of frequent interactional trouble in dementia care which have not previously been articulated.

Primary paper is available from Social Science & Medicine

NIHR Alert Careful phrasing of requests by hospital staff could help people with dementia accept care

Cambridge Research: Apathy could predict onset of dementia years before other symptoms

University of Cambridge | October 2020 |Apathy could predict onset of dementia years before other symptoms

A team of researchers led by Professor James Rowe at the University of Cambridge have shown how apathy predicts cognitive decline even before the dementia symptoms emerge. 

This longitudinal study followed 304 healthy participants who carry a faulty gene that causes frontotemporal dementia (FTD), and 296 of their relatives who have normal genes. All particpants were assessed at the outset of the study and every two years over several years. None had dementia, and most people in the study did not know whether they carry a faulty gene or not. The researchers looked for changes in apathy, memory tests and MRI scans of the brain, and they found that apathy severity increased over time in presymptomatic carriers, but not in non‐carriers. Among those who carried the gene , baseline gray matter volume of frontal lobe and cingulate cortex predicted the faster progression of apathy over 2 years. (Source: Malpetti, et al, 2020 & University of Cambridge).

“By studying people over time, rather than just taking a snapshot, we revealed how even subtle changes in apathy predicted a change in cognition, but not the other way around,” explained Malpetti, the study’s first author. “We also saw local brain shrinkage in areas that support motivation and initiative, many years before the expected onset of symptoms. The more we discover about the earliest effects of frontotemporal dementia, when people still feel well in themselves, hte better we can treat symptoms and delay or even prevent the dementia.

First author of the study Dr Maura Malpetti

The paper discusses how apathy is an early marker of FTD‐related changes and predicts a subsequent subclinical deterioration of cognition before dementia onset.

Malpetti, M. et al (2020)| Apathy in presymptomatic genetic frontotemporal dementia predicts cognitive decline and is driven by structural brain changes| Alzheimer’s & Dementia |https://doi.org/10.1002/alz.12252

Abstract
Introduction

Apathy adversely affects prognosis and survival of patients with frontotemporal dementia (FTD). We test whether apathy develops in presymptomatic genetic FTD, and is associated with cognitive decline and brain atrophy.

Methods

Presymptomatic carriers of MAPTGRN or C9orf72 mutations (N = 304), and relatives without mutations (N = 296) underwent clinical assessments and MRI at baseline, and annually for 2 years. Longitudinal changes in apathy, cognition, gray matter volumes, and their relationships were analyzed with latent growth curve modeling.

Results

Apathy severity increased over time in presymptomatic carriers, but not in non‐carriers. In presymptomatic carriers, baseline apathy predicted cognitive decline over two years, but not vice versa. Apathy progression was associated with baseline low gray matter volume in frontal and cingulate regions.

Discussion

Apathy is an early marker of FTD‐related changes and predicts a subsequent subclinical deterioration of cognition before dementia onset. Apathy may be a modifiable factor in those at risk of FTD.

Primary paper is published in the journal Alzheimer’s & Dementia

University of Cambridge Apathy could predict onset of dementia years before other symptoms

Apathy in presymptomatic genetic frontotemporal dementia predicts cognitive decline and is driven by structural brain changes

In the news:

Science Daily Apathy could predict onset of dementia years before other symptoms

The Daily Mail Apathy and lack of motivation in your mid-forties could be an early warning sign of dementia, study suggests

NIHR: Dementia Care Mapping: Care home managers and staff need more support to improve care

“I was surprised at just how variable the implementation of DCM was, and how difficult many of the homes found it, particularly given it is an interevention already in use in care homes. We knew we would see some turnover of staff but there was much more managerial turnover than we expected and the impacts of this were greater on the intervention than we anticipated.”

Study Author Rachel Kelley,
Dementia Researcher, Leeds Beckett University
An NIHR- funded study looked at why implementation of the dementia care mapping has failed to lead to improvements in some care homes. The authors of the study found that implementation is patchy and vulnerable to issues such as staff and manager turnover, their confidence or skills to lead changes in practice, and inadequate staffing and funds.

Previous studies (not in the UK) reported that that DCM had mixed results across care homes. Where DCM was led by the researchers, there were some benefits for residents and staff. However, where DCM was led by care home staff, no benefits were found and there were problems implementing the tool.

This study explored the barriers and facilitators in introducing a complex tool like DCM, including the influence of care home managers. It interviewed almost 50 care home managers who were also participants in the intervention arms of a related trial.

Study Author Rachel Kelley said, “overall the findings show just how important support for care homes and their managers and staff is when we are trying to implement new interventions and practices. It is important to say there were definitely examples of care homes that implemented DCM well and where the staff thought it was beneficial. Other homes wanted to implement it, but were unable to for a variety of reasons, as our study showed.” (Source: NIHR)

Read the full NIHR article Dementia Care Mapping: Care home managers and staff need more support to improve care

The primary paper is available from BMC Geriatrics Kelley R, and others. The influence of care home managers on the implementation of a complex intervention: findings from the process evaluation of a randomised controlled trial of dementia care mappingBMC Geriatrics. 2020;20:303

Dementia and outcomes from coronavirus disease 2019 pneumonia

Dementia and outcomes from coronavirus disease 2019 (COVID-19) pneumonia: A systematic review and meta-analysis | Archives of Gerontology and Geriatrics November 2020

The number of positive and death cases from coronavirus disease 2019 (COVID-19) is still increasing until now. One of the most prone individuals, even in normal situations is patients with dementia. Currently, no study provides clear evidence regarding the link between dementia and COVID-19. This study aims to analyze the relationship between dementia and poor outcomes of COVID-19 infection.

A total of 24 studies with 46,391 dementia patients were included in this meta-analysis. This study showed that dementia was associated with composite poor outcome and its subgroup which comprised of risk of COVID-19 infection, and mortality from COVID-19 infection.

The authors conclude that extra care and close monitoring should then be provided to patients with dementia to minimize the risk of infections, preventing the development of severe and mortality outcomes.

Full article: Dementia and outcomes from coronavirus disease 2019 pneumonia

Cochrane: Activities for people with dementia: what can evidence and experience teach us?

In this blog Sarah Chapman looks at evidence on personally tailored activities for people with dementia and shares insights from her own experience and those of others, acknowledging a wealth of experience to help people with dementia, while we await further research into providing tailored activities for people with dementia.

Blog post available from Evidently Cochrane

NIHR: The WHELD programme for people with dementia helps care home staff deliver person-centred care

NIHR |  December 2020 | The WHELD programme for people with dementia helps care home staff deliver person-centred care

An evidence-based programme for care home residents living with dementia improved their quality of life and reduced agitation and other symptoms of dementia. A major study across the UK found that the Well-being and Health for People Living with Dementia (WHELD) programme was effective and cost less to deliver than usual care.

The research design of this study employed a large randomised clinical trial, the involvement of 69 care homes and participation of 847 residents, over a 9 month period. The experts aimed to to determine if training in person-centred care could be enhanced through review of antipsychotic prescriptions, promotion of social interaction/personalised activities or exercise. Combining personalised activities with a review of antipsychotic medication led to reduction in antipsychotic use by a half as well as a significant improvement in some aspects of quality of life for residents with dementia. There was also a significant reduction in mortality. There were improvements in symptoms of agitation among people receiving the exercise intervention.

.The results demonstrated benefits in quality of life, a reduction in agitation and improvement in quality of care for re

The researchers report that for care home residents with dementia, involvement in the programme led to:

  • significant benefits in quality of life
  • a reduction in agitation
  • a reduction in neuropsychiatric symptoms such as depression
  • improvement in quality of care, with residents experiencing fewer emergency hospital admissions and fewer GP visits.

The researchers behind this study have also secured further funding from NIHR to develop a COVID-specific version of the WHELD programme. This will use virtual coaching and use digital platforms to share best practice between staff and managers of different care homes (Source: NIHR)

The primary paper is available from NIHR

More information about the WHELD programme is available from its website Help us Shape the Future of Care

Video about the WHELD programme, including interviews with care home staff.

The music project helping dementia patients find their voice during lockdown

Wertheimer, F. 18 November 2020| The Guardian |The music project helping dementia patients find their voice during lockdown
The music project helping dementia patients find their voice during lockdown via The Guardian

This news story tells how a Manchester orchestra that usually provides session to care residents including people with dementia, had to stop its award-winning work due to the pandemic. Happily, the nine musicians and two music therapists who comprise Manchester’s Camerata Orchestra Music in Mind project are now delivering their sessions virtually.

Read the news story from The Guardian