Objective: To summarise existing systematic reviews that assess the effects of non-pharmacological, pharmacological and alternative therapies on activities of daily living (ADL) function in people with dementia.
Design: Overview of systematic reviews.
Methods: A systematic search in the Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE and PsycInfo in April 2015. Systematic reviews of randomised controlled trials conducted in people with Alzheimer’s disease or dementia measuring the impact on ADL function were included. Methodological quality of the systematic reviews was independently assessed by two authors using the AMSTAR tool. The quality of evidence of the primary studies for each intervention was assessed using GRADE.
Results: A total of 23 systematic reviews were included in the overview. The quality of the reviews varied; however most (65%) scored 8/11 or more on the AMSTAR tool, indicating high quality. Interventions that were reported to be effective in minimising decline in ADL function were: exercise (6 studies, 289 participants, standardised mean difference (SMD) 0.68, 95% CI 0.08 to 1.27; GRADE: low), dyadic interventions (8 studies, 988 participants, SMD 0.37, 95% CI 0.05 to 0.69; GRADE: low) acetylcholinesterase inhibitors and memantine (12 studies, 4661 participants, donepezil 10 mg SMD 0.18, 95% CI 0.03 to 0.32; GRADE: moderate), selegiline (7 studies, 810 participants, SMD 0.27, 95% CI 0.13 to 0.41; GRADE: low), huperzine A (2 studies, 70 participants, SMD 1.48, 95% CI 0.95 to 2.02; GRADE: very low) and Ginkgo biloba (7 studies, 2530 participants, SMD 0.36, 95% CI 0.28 to 0.44; GRADE: very low).
Conclusions: Healthcare professionals should ensure that people with dementia are encouraged to exercise and that primary carers are trained and supported to provide safe and effective care for the person with dementia. Acetylcholinesterase inhibitors or memantine should be trialled unless contraindicated.
Bunn, F. et al. Health Services and Delivery Research, No. 4.8
Background: Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.
Objectives: To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.
Design: We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.
Participants:The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.
Results: The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.
Conclusions:Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.
Objective: Little is known about how and to what extent people with dementia live positively with their condition. This study aimed to review and carry out a synthesis of qualitative studies where accounts of the subjective experiences of people with dementia contained evidence of positive states, experiences or attributes.
Methods: A meta-synthesis was undertaken to generate an integrated and interpretive account of the ability of people with dementia to have positive experiences. A methodological quality assessment was undertaken to maximize the reliability and validity of this synthesis and to contextualize the findings with regard to methodological constraints and epistemological concepts.
Findings: Twenty-seven papers were included. Three super-ordinate themes relating to positive experiences and attributes were identified, each with varying and complementing sub-themes. The first super-ordinate theme related to the experience of engaging with life in ageing rather than explicitly to living with dementia. The second theme related to engaging with dementia itself and comprised the strengths that people can utilize in facing and fighting the condition. The third theme captured how people with dementia might transcend the condition and seek ways to maintain identity and even achieve personal growth.
Conclusions: This review provides a first step towards understanding what conceptual domains might be important in defining positive outcomes for people who live with dementia. Highlighting the potential for people to have positive experiences in spite of or even because of their dementia has important implications for de-stigmatizing dementia and will enhance person-centred approaches to care.
Qian, Z.J. et al. The American Journal of Geriatric Psychiatry. Published online: 12 April 2016
Objectives: Hearing loss is associated with cognitive decline in the elderly. However, it is unknown if the use of hearing aids (HAs) is associated with enhanced cognitive function.
Design: Cross-sectional study.
Setting: Academic medical center.
Measurements: Participants underwent audiometric evaluation, the Mini-Mental State Examination (MMSE), and the Trail Making Test, Part B (TMT-B). The impact of use versus disuse of HAs was assessed. Performance on cognitive tests was then compared to unaided hearing levels.
Results: HA users performed better on the MMSE (1.9 points; rank-sum, p=0.008) despite having worse hearing at both high frequencies (15.3 dB hearing level; t-test, p<0.001) and low frequencies (15.7 dB hearing level; t-test p<0.001). HA use had no effect TMT-B performance. Better performance on the MMSE was correlated with both low frequency (ρ=-0.28, p=0.021) and high frequency (ρ=-0.21, p=0.038) hearing level, but there was no correlation between performance on the TMT-B and hearing at any frequency.
Conclusions: Despite having poorer hearing, hearing aid users performed better on the MMSE. Better performance on cognitive tests with auditory stimuli (MMSE) but not visual stimuli (TMT-B) suggests that hearing loss is associated with sensory-specific cognitive decline rather than global cognitive impairment. As hearing loss is nearly universal in those >80 years, hearing aids should be strongly recommended to minimize the cognitive impairment in the elderly.
Andrieu, S. et al. Alzheimer’s & Dementia. Volume 12, Issue 4. April 2016. Pp. 427–437
Introduction: Quality of life (QOL) is an important dimension to consider in Alzheimer’s disease (AD), but few large-scale studies have analyzed self and caregiver reports of patient QOL.
Methods: Patient QOL was evaluated in a cohort of 574 AD patients with the QOL-AD scale over 2 years.
Results: Caregiver reports of patient QOL were lower at baseline than self reports. Older patient age was associated with overestimation of QOL by caregivers, whereas neuropsychiatric inventory score and caregiver burden were associated with underestimation. Activities of daily living limitation, depressive symptoms, and caregiver burden were systematically associated with poorer QOL, whereas caregiver relationship and apathy were associated with poorer QOL only for self reports or caregiver reports, respectively. Cognitive function and professional care were not associated with QOL. Self-rated patient QOL did not change over time, whereas disease severity markers and caregiver-rated patient QOL declined.
Discussion: It is important to assess both self and caregiver ratings when assessing patient QOL.
White, C. OnMedica. Published online: 20 April 2016
The prevalence of dementia in the UK may not be increasing as fast as has been feared, say researchers after reporting a 20% drop in the numbers of new cases diagnosed between 1989 and 2011 in a study published online in Nature Communications.
The researchers compared the actual number of dementia cases in the UK with figures from earlier decades and previous predictions.
Between their two sample periods of 1989-94 and 2008-11, the incidence of the disease fell by 20%—but predominantly in men, among whom new cases in those over 80 almost halved during those periods, the findings show.
Two thirds of new cases will be in women, who seem to be at a higher risk of developing dementia than men, irrespective of their longevity advantage over men, the findings indicate.
RemoDem aimed to develop, test and evaluate services for people with dementia in remote areas of the Faroe Islands, Greenland, Sweden and Scotland. Formative and summative evaluation used a flexible research design including collection of baseline data, interviews and focus groups with key informants and data relating to service users, i.e. people with dementia and their carers.
Challenges for service providers included organisational difficulties, lack of clear information about their populations with dementia and lack of knowledge in local communities. Test sites which developed services building on their particular local starting points adopted both specialist and ‘off the shelf’ technologies and found that these were generally helpful for people with significant support needs.
Services were more successful where more mature and less experimental technologies were used. The new services promised to address effectively challenges of remoteness including distance, communication and workforce deployment issues.
Fourteen people attending an adult day programme were recruited to a structured horticultural therapy programme which took place over 10 weeks. The effects were assessed using Dementia Care Mapping and questionnaires completed by family carers.
High levels of wellbeing were observed while the participants were engaged in horticultural therapy, and these were sustained once the programme was completed. This study adds to the growing evidence on the benefits of horticultural therapy for people with dementia who have enjoyed gardening in the past.
Conroy, S.P. Age Ageing. Published online: April 7, 2016
Background: ambulatory blood pressure monitoring (ABPM) may be helpful for the management of hypertension, but little is known about its tolerability in people with dementia.
Objective: to review the published evidence to determine the tolerability of ABPM in people with dementia.
Methods: English language search conducted in MEDLINE and EMBASE, using ‘Ambulatory blood pressure’ AND ‘Dementia’ (and associated synonyms) from 1996 to March 2015. Inclusion criteria: people diagnosed with dementia AND in whom blood pressure was measured using ABPM. The initial search was undertaken using title and abstract reviews, with selected papers being agreed for inclusion by two reviewers. Potentially eligible papers were assessed, and high-quality papers were retained. Two reviewers agreed the abstracted data for analysis. Meta-analysis was used to combine results across studies.
Results: of the 221 screened abstracts, 13 studies (6%) met inclusion criteria, 5 had sufficient data and were of sufficient quality, involving 461 participants, most of whom had mild–moderate dementia. 77.7% (95% CI 62.2–93.2%) were able to tolerate ABPM; agreement with office BP was moderate to weak (two studies only—coefficients 0.3–0.38 for systolic blood pressure and 0.11–0.32 for diastolic blood pressure). One study compared home BP monitoring by a relative or ambulatory BP monitoring with office BP measures and found high agreement (κ 0.81). The little available evidence suggested increased levels of dementia being associated with reduced tolerability.
Conclusions: ABPM is well tolerated in people with mild–moderate dementia and provides some additional information over and above office BP alone. However, few studies have addressed ABPM in people with more severe dementia.
NHS England’s new National Clinical Director for Older People and Integrated Care has released an initial statement of intent concerning future directions in national ageing policy and the NHS commissioning.
“As the new NCD for Older People I intend to pursue all available opportunities for preventative, collaborative care offered by identification of pre- and moderate frailty… ”
Dr Martin Vernon’s exact job-title varies from sentence to sentence (which matters little), but some interesting priorities are announced.