People with dementia in care homes need pharmacist-led medicine reviews

by Laurence Thraves for the RPS Blog

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Image source: e-magine art

70 per cent of people with dementia have one or more other long-term health condition. As GPs and other medical professional try to treat these conditions, people with dementia can end up on a cocktail of drugs that exacerbate their symptoms. Using their specialist skills, pharmacists can play a vital role in improving how medicines are used in care homes and, as a result, the quality of life for the 280,000 people with dementia living there.

Co-morbidities have a complex relationship with dementia: either acting as a precursor to it, a result of it, or being entirely incidental. High blood pressure and diabetes can increase a person’s risk of developing dementia; having stroke can cause dementia; and depression can come as a consequence.  It’s no surprise, then, that the Royal Pharmaceutical Society has found that care home residents are taking an average of seven to eight medicines a day – some are taking double or treble this amount.

It’s likely that, in many cases, people with dementia are taking some drugs unnecessarily. As one prescription is added to another and another, the drug burden increases, along with the likelihood of drug interactions or exacerbation of symptoms.  This can lead to devastating consequences for the person’s health and quality of life, such as falls, malnutrition, social isolation, unnecessary hospital stays.

The role of the pharmacist in improving the quality of dementia care in care homes cannot be underestimated. Reviewing medications annually, in coordination with GPs, or when medications change or a resident moves, will help ensure that more people with dementia are taking the right drugs at the right time. The fact that this could save the NHS up to £135 million, while improving outcomes for people with dementia, mean that there’s no excuse for commissioners not making this happen.

Read the full blog here

Communication And Respect for people with Dementia

This paper discusses an educational programme designed for multiple disciplines to improve healthcare students’ preparedness to work with people with dementia. It consisted of class-based sessions followed by a volunteer experience interacting with persons with dementia in care homes. This paper discusses the value and impact of this innovative experience.

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image source: http://dem.sagepub.com/

Wood, J.H. Communication And Respect for people with Dementia: Student learning – A novel practical experience of undergraduate students interacting with people with dementia in care homes (innovative practice)  Dementia. Published online before print February 23, 2016. 

Day care centres for people with dementia

The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature.
Aging & Mental Health Volume 20, Issue 5, 2016

Objectives: Day care centres (DCC) for people with dementia (PWD) have received increased attention recently, due to a shift in policy from the use of residential care towards home-based services. The aim of this study is to provide an extended understanding of the influence of DCCs on family caregivers (FCs).

Method: An integrative review including 19 studies was used: qualitative (n = 2), quantitative non-randomised (n = 8), quantitative descriptive studies (n = 7), and with mixed-method design (n = 2). The quality of the studies was evaluated by the mixed-methods appraisal tool (MMAT).

Results: FC experienced the DCC both as a respite service, and to some extent as a support service, improving their competence in caring for the PWD. The quality of the DCC influenced its use, and the FC’s motivation to care for the PWD. FC’s gender, role, individual needs, PWD behavioural problems and need for assistance played an important role.

Conclusion: As a respite and support service, DCCs have the potential to give FCs a feeling of safety and relief, reduce the caregiver’s burden, and increase their motivation towards their role as caregivers. These outcomes depend on the quality of treatment, and how the service meets the FC’s needs for flexibility, support, information, and responsibility sharing.

Statins for the prevention of dementia

McGuinness, B. et al. Cochrane Dementia and Cognitive Improvement Group. Published Online: 4 January 2016

Background: This is an update of a Cochrane review first published in 2001 and then updated in 2009. Vascular risk factors including high cholesterol levels increase the risk of dementia due to Alzheimer’s disease and of vascular dementia. Some observational studies have suggested an association between statin use and lowered incidence of dementia.

Objectives: To evaluate the efficacy and safety of statins for the prevention of dementia in people at risk of dementia due to their age and to determine whether the efficacy and safety of statins for this purpose depends on cholesterol level, apolipoprotein E (ApoE) genotype or cognitive level.

 

Main results: We included two trials with 26,340 participants aged 40 to 82 years of whom 11,610 were aged 70 or older. All participants had a history of, or risk factors for, vascular disease. The studies used different statins (simvastatin and pravastatin). Mean follow-up was 3.2 years in one study and five years in one study. The risk of bias was low. Only one study reported on the incidence of dementia (20,536 participants, 31 cases in each group; odds ratio (OR) 1.00, 95% confidence interval (CI) 0.61 to 1.65, moderate quality evidence, downgraded due to imprecision). Both studies assessed cognitive function, but at different times using different scales, so we judged the results unsuitable for a meta-analysis. There were no differences between statin and placebo groups on five different cognitive tests (high quality evidence). Rates of treatment discontinuation due to non-fatal adverse events were less than 5% in both studies and there was no difference between statin and placebo groups in the risk of withdrawal due to adverse events (26,340 participants, 2 studies, OR 0.94, 95% CI 0.83 to 1.05).

Authors’ conclusions: There is good evidence that statins given in late life to people at risk of vascular disease do not prevent cognitive decline or dementia. Biologically, it seems feasible that statins could prevent dementia due to their role in cholesterol reduction and initial evidence from observational studies was very promising. However, indication bias may have been a factor in these studies and the evidence from subsequent RCTs has been negative. There were limitations in the included studies involving the cognitive assessments used and the inclusion of participants at moderate to high vascular risk only.

Read the full reviews here

Is the Mediterranean diet a feasible approach to preserving cognitive function and reducing risk of dementia for older adults in Western countries? New insights and future directions.

Knight, A. et al. Ageing Research & Reviews. 2016 Jan;25:85-101

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Image source: USDA

Abstract:

The rise in the ageing population has resulted in increased incident rates of cognitive impairment and dementia. The subsequent financial and societal burden placed on an already strained public health care system is of increasing concern.

Evidence from recent studies has revealed modification of lifestyle and dietary behaviours is, at present, the best means of prevention. Some of the most important findings, in relation to the Mediterranean diet (MedDiet) and the contemporary Western diet, and potential molecular mechanisms underlying the effects of these two diets on age-related cognitive function, are discussed in this review.

A major aim of this review was to discuss whether or not a MedDiet intervention would be a feasible preventative approach against cognitive decline for older adults living in Western countries. Critical appraisal of the literature does somewhat support this idea. Demonstrated evidence highlights the MedDiet as a potential strategy to reduce cognitive decline in older age, and suggests the Western diet may play a role in the aetiology of cognitive decline. However, strong intrinsic Western socio-cultural values, traditions and norms may impede on the feasibility of this notion.

Read the abstract here

The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials.

Groot, C. et al. Ageing Research Reviews. 2016 Jan;25:13-23

Social Care Photography, Department of Health

Abstract:

Non-pharmacological therapies, such as physical activity interventions, are an appealing alternative or add-on to current pharmacological treatment of cognitive symptoms in patients with dementia.

In this meta-analysis, we investigated the effect of physical activity interventions on cognitive function in dementia patients, by synthesizing data from 802 patients included in 18 randomized control trials that applied a physical activity intervention with cognitive function as an outcome measure. Post-intervention standardized mean difference (SMD) scores were computed for each study, and combined into pooled effect sizes using random effects meta-analysis.

The primary analysis yielded a positive overall effect of physical activity interventions on cognitive function (SMD[95% confidence interval]=0.42[0.23;0.62], p<.01).

Secondary analyses revealed that physical activity interventions were equally beneficial in patients with Alzheimer’s disease (AD, SMD=0.38[0.09;0.66], p<.01) and in patients with AD or a non-AD dementia diagnosis (SMD=0.47[0.14;0.80], p<.01). Combined (i.e. aerobic and non-aerobic) exercise interventions (SMD=0.59[0.32;0.86], p<.01) and aerobic-only exercise interventions (SMD=0.41[0.05;0.76], p<.05) had a positive effect on cognition, while this association was absent for non-aerobic exercise interventions (SMD=-0.10[-0.38;0.19], p=.51).

Finally, we found that interventions offered at both high frequency (SMD=0.33[0.03;0.63], p<.05) and at low frequency (SMD=0.64[0.39;0.89], p<.01) had a positive effect on cognitive function.

This meta-analysis suggests that physical activity interventions positively influence cognitive function in patients with dementia. This beneficial effect was independent of the clinical diagnosis and the frequency of the intervention, and was driven by interventions that included aerobic exercise.

Read the abstract here

Post-diagnostic dementia care

Alistair Burns. SCIE. 15th February 2016.

‘Many of us start the new year with a resolution. So it’s a good time for those of us, committed to making England a better place for people with dementia to live, to make the following one. Find out all about the recently-launched joint declaration on post-diagnostic dementia care and support and support it. Once a person with dementia has received a diagnosis it is essential that they get ongoing appropriate post-diagnostic care.

Government, health, social care and the third sector can work together to deliver high quality services to people living with dementia and their families. That’s what the new joint declaration by these bodies hopes to achieve. I’ve written recently on the NHS England blog about some of the challenges for finding medical treatments for dementia and its commonest causes. But what about care and support when someone actually has the condition?

I know SCIE is committed to improving the care and support that people living with dementia deserve. For instance, a film on their site from 2015 shows what it might feel like to live with dementia. Viewers will experience a little of what it is like to find yourself in a world that seems familiar and yet doesn’t always make sense. The incidents pictured in the film and memories recounted are based upon true experiences gathered from people living with dementia.’

Carry on reading the full article here