Physical function and depression in nursing home residents with dementia

Among elderly people in general, better physical function is associated with lower incidence of depressive symptoms. It is also related to better mental health, quality of life and well-being | BMJ Open

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Image source: sima dimitric – Flickr // CC BY 2.0

Objectives: The primary aim of this study is to describe depression and physical function in nursing home residents with dementia, as well as to examine the associations between depression and balance function, lower limb muscle strength, mobility and activities of daily living. The secondary aim is to examine the differences in physical function between the groups classified as depressed and not depressed.

Results: Nursing home residents with dementia are a heterogeneous group in terms of physical function and depression. By applying the recommended cut-off of 8 on CSDD, 23.5% of the participants were classified as being depressed. The results revealed significant associations between higher scores on CSDD (indicating more symptoms of depression) and lower scores on BBS (95% CI −0.12 to −0.02, p=0.006), 30 s CST (95% CI −0.54 to −0.07, p=0.001) as well as maximum walking speed (95% CI −4.56 to −0.20, p=0.003) (indicating lower level of physical function).

Conclusion: Better muscle strength, balance and higher walking speed were significantly associated with less depressive symptoms. The potential interaction of dementia with poor physical function and depression indicates an area to explore in future epidemiological studies with a prospective design.

Full reference: Kvæl, L.A.H. et al.  (2017) Associations between physical function and depression in nursing home residents with mild and moderate dementia: a cross-sectional study. BMJ Open. 7:e016875.

Latest statistics on dementia prevalence in England

Annual report brings together GP-level data on recorded dementia diagnoses.

The latest statistics on dementia prevalence in England have been published by NHS Digital.  Recorded Dementia Diagnoses 2016/17 uses information provided by general practices in England about the number of dementia diagnoses in their individual practice.

For each general practice included in this data collection, NHS Digital receives a count of the number of patients with a dementia diagnosis in their clinical record, as well as a count of the total number of registered patients at the practice.

Key Facts:

In 2016-17:

  • 422,000 people aged 65 and over in England have a recorded dementia diagnosis. This represents 1 in 23 people aged 65+ registered with a GP.
  • 1 in 5 women aged 90 or over have a recorded dementia diagnosis, the highest prevalence for any group.
  • There were 207,797 unique patients aged 65 and over admitted to hospital in an emergency with a diagnosis of dementia (provisional data).
  • Dementia is more common in people with learning disabilities, particularly for individuals with Down syndrome who appear to develop dementia at younger ages

The report also covers topics such as:

  • Dementia related emergency hospital admissions (England)
  • Dementia prevalence for patients with learning disabilities
  • Recorded dementia diagnoses by ethniticy and age

People with dementia benefit from goal-orientated therapy

Personalised cognitive rehabilitation therapy can help people with early stage dementia significantly improve their ability to engage in important everyday activities and tasks. | via ScienceDaily

A large-scale trial has found that cognitive rehabilitation leads to people seeing satisfying progress in areas that enable them to maintain their functioning and independence.

Cognitive rehabilitation involves a therapist working with the person with dementia and a family carer to identify issues where they would like to see improvements. Together, they set up to three goals, and the therapist helps to develop strategies to achieve these goals.

The goals participants chose were varied, as dementia affects people in a wide range of ways. Some participants wanted to find ways of staying independent, for example by learning or re-learning how to use household appliances or mobile phones. Some wanted to manage daily tasks better, and worked with therapists on developing strategies to prevent them burning their food when cooking meals. Others wanted to stay socially connected, and focussed on being able to remember details like the names of relatives or neighbours, or improving their ability to engage in conversation. Sometimes staying safe was important, so strategies focused on things like remembering to lock the door at home or withdrawing money safely from a cashpoint.

The Goal-oriented Cognitive Rehabilitation in Early-stage Alzheimer’s and Related Dementias: Multi-centre Single-blind Randomised Controlled Trial (GREAT) trial involved 475 people across eight sites in England and Wales. Half of them received ten cognitive rehabilitation sessions over three months, and the other half did not. The group receiving the therapy then took part in four “top-up” sessions over six months.

The researchers found that those who took part in the therapy showed significant improvement in the areas they had identified, after both the ten week and “top-up” sessions. Family carers agreed that their performance had improved. Both participants and carers were happier with the participants’ abilities in the areas identified.

Full story: University of Exeter. “People with dementia benefit from goal-oriented therapy: Personalized cognitive rehabilitation therapy can help people with early stage dementia significantly improve their ability to engage in important everyday activities and tasks.” ScienceDaily. | 18 July 2017.

The prevalence of comorbid cancer and dementia

Findings suggest that dementia is associated with poorer cancer outcomes

Objectives: A comorbid diagnosis of cancer and dementia (cancer–dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer–dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care.

Method: Databases were searched  using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer–dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively.

Results: Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer–dementia prevalence rates (range 0.2%–45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer–dementia despite greater health service use.

Conclusions: There is a dearth of good-quality evidence investigating the cancer–dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer–dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Full reference: L. McWilliams, C et al. | A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care | Aging & Mental Health |  Published online: 18 Jul 2017

Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals

The aim of this study was to identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia | BMJ Open.

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Results: Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context–mechanism–outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress.

Conclusions: This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes.

Full reference: Handley, M. et al. (2017) Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review. BMJ Open. 7:e015257

Caring for an individual with mild cognitive impairment

Little is known regarding the effect that caring for an individual with Mild Cognitive Impairment (MCI) has on health-related quality of life (HRQOL) | Aging & Mental Health 

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Objectives: We sought to identify the most important aspects of HRQOL related to caring for an individual with MCI.

Results: Findings indicated that caregivers most frequently discussed social health, including changes in social roles and an increased need for social support (51.2% of the total discussion). This was followed by mental health concerns (37.9%) centering on anger/frustration, and a need for patience in the caregiving role, as well as caregiver-specific anxiety. Other topics included physical health (10.0%; including the impact that stress and burden have on medical heath), and caregivers’ cognitive health (0.9%; including memory problems in relation to caregiver strain, sleep disruption, and cognitive fatigue).

Conclusions: Findings illustrate the multiple domains of HRQOL that are affected in individuals providing care for someone with MCI. Moreover, the findings highlight the need for extending support services to MCI caregivers, a group that is typically not offered support services due to the ‘less severe’ nature of an MCI diagnosis.

Full reference: Carlozzi, N.E. et al. (2017) Caring for an individual with mild cognitive impairment: a qualitative perspective of health-related quality of life from caregivers. Aging & Mental Health. Published online: 12 Jul 2017

How people with dementia and carers understand and react to social functioning changes

This study aims to analyse people with dementia and their family carers’ attribution of social changes in dementia and the consequences of these attributions | BMJ Open

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Image source: Mauri – Flickr // CC BY 2.0

Design: Qualitative study, using a semi-structured interview guide. Individual interviews continued to theoretical saturation. Two researchers independently analysed interview transcripts.

Results: We interviewed nine people with dementia and nine carers, encompassing a range of age, ethnicity and educational backgrounds. Both groups reported that the person with dementia had changed socially. People with dementia tended to give one or two explanations for social change, but carers usually suggested several. People with dementia were often socially embarrassed or less interested in going out, and they or their relatives’ physical illness or fear of falls led to reduced social activity. Carers often attributed not going out to a choice or premorbid personality. Carers found that their relative needed more support to go out than they could give and carers needed time to themselves because of carer stress or other problems from which they shielded the person with dementia. Additionally, there was decreased opportunity to socialise, as people were bereaved of friends and family. Participants acknowledged the direct impact of dementia symptoms on their ability to socially engage but sometimes decided to give up socialising when they knew they had dementia. There were negative consequences from social changes being attributed to factors such as choice, rather than dementia.

Conclusion: Clinicians should ask about social changes in people with dementia. Explaining that these may be due to dementia and considering strategies to overcome them may be beneficial.

Full reference: Singleton, D. et al (2017) How people with dementia and carers understand and react to social functioning changes in mild dementia: a UK-based qualitative study. BMJ Open. 7:e016740

The effect of music therapy on cognitive functions in patients with dementia.

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Objectives: The aim of the present study was to meta-analyze the effect of music therapy (MT) on cognitive functions in patients with dementia.

Method: A systematic literature search was performed in Medline, PsycINFO, Embase, CINAHL and RILM up to 8 September 2016. We included all randomized controlled trials that compared MT with standard care, or other non-musical types of intervention, evaluating cognitive outcomes in patients with dementia. Outcomes included global cognition, complex attention, executive function, learning and memory, language, and perceptual-motor skills.

Results: From 1089 potentially relevant records, 110 studies were assessed for eligibility, and 7 met the inclusion criteria, of which 6 contained appropriate data for meta-analysis (330 participants, mean age range 78.8–86.3). Overall, random-effects meta-analyses suggested no significant effects of MT on all outcomes. Subgroup analysis found evidence of a beneficial effect of active MT on global cognition (SMD = 0.29, 95% CI 0.02 to 0.57, p = 0.04).

Conclusion: Despite the limited evidence of the present review, it is important to continue supporting MT as a complementary treatment for older adults with dementia. RCTs with larger sample sizes are needed to better elucidate the impact of MT on cognitive functions.

Full reference: The effect of music therapy on cognitive functions in patients with dementia: a systematic review and meta-analysis   | Aging & Mental Health | Published online: 10 Jul 2017

Delayed-onset post-traumatic stress disorder symptoms in dementia

In this review, Tarun Kuruvilla et al. consider three examples of delayed-onset PTSD and its frequent association, or misdiagnosis, as one of the numerous manifestations of the behavioural and psychological symptoms of dementia | Progress in Neurology and Psychiatry

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Image source: Progress in Neurology and Psychiatry

Dementia sufferers commonly experience non-cognitive symptoms as their disease progresses. These symptoms are often labelled as behavioural and psychological symptoms of dementia (BPSD) and encompass a broad range of symptoms relating to mood changes such as depression and anxiety, psychosis, and inappropriate behaviours like wandering, shouting and agitation. Post-traumatic stress disorder (PTSD) is a common diagnosis amongst working-age adults but it is infrequently diagnosed in the elderly, particularly those with dementia. Previous case reports have published examples of dementia sufferers experiencing post-traumatic stress disorder symptoms long after the original traumatic event. Despite these examples, little is known about the manifestation of traumatic exposure in the older adult population. We consider whether delayed-onset post-traumatic symptoms in the elderly are being misdiagnosed, instead falling under the umbrella of BPSD. In this article, we attempt to expand on previous work by describing three cases of delayed-onset PTSD associated with the development of dementia. We explore potential biological and psychosocial theories to explain the aetiology of these symptoms with reference to the literature. We end by considering the clinical implications for future practice, including suggestions for improved diagnosis and management.

Full reference: Martinez-Clavera, C. et al. (2017) Delayed-onset post-traumatic stress disorder symptoms in dementia. Progress in Neurology and Psychiatry. Vol. 21 (no. 03).

Computerized game-based training method in people with dementia

This study aims to examine the effects of a computerized, game-based training on motor-cognitive performances, the transfer of training effects on untrained tasks, and the sustainability of training gains in people with dementia | Aging & Mental Health 

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Method: Ninety-nine individuals with a mean age of 82.9 (5.8) and dementia participated in a 10-week randomized controlled trial with three-month follow-up. The intervention group (IG) received a motor-cognitive training on (Physiomat®) including concurrent dual-tasks of balance control with cognitive demands (Physiomat®-Trail Making Tasks (PTMTs)). The control group (CG) performed non-specific, low-intensity exercises. Duration and accuracy at different complexity levels of trained and untrained PTMTs and the number of successfully performed tasks (PTMT score) were assessed.

Results: Physiomat® training significantly improved the duration and accuracy at almost all complexity levels of trained (P ≤ 0.001–0.047, ηp2 = 0.065–0.589) and untrained PTMTs (P < 0.001–0.005, ηp2 = 0.073–0.459). Significant effects were also found for the PTMT score of trained (P < 0.001, ηp2 = 0.211) and untrained PTMTs (P < 0.001, ηp2 = 0.184). Training gains were partly sustained at follow-up.

Conclusion: Physiomat® is feasible and has the potential to sustainably improve motor-cognitive performances in people with dementia.

Full reference: Wiloth, S. et al. (2017) Motor-cognitive effects of a computerized game-based training method in people with dementia: a randomized controlled trial. Aging & Mental Health. Published online: 6th July 2017