Psychosocial interventions for people with dementia

Orii McDermott | et al. | Psychosocial interventions for people with dementia: a synthesis of systematic reviews | Aging & Mental Health | Volume 23:4 | p393-403

Objectives: Over the last 10 years there has been a multitude of studies of psychosocial interventions for people with dementia. However, clinical services face a dilemma about which intervention should be introduced into clinical practice because of the inconsistency in some of the findings between different studies and the differences in the study qualities and trustworthiness of evidence. There was a need to provide a comprehensive summary of the best evidence to illustrate what works.

Methods: A review of the systematic reviews of psychosocial interventions in dementia published between January 2010 and February 2016 was conducted.

Results: Twenty-two reviews (8 physical, 7 cognitive, 1 physical/cognitive and 6 other psychosocial interventions) with a total of 197 unique studies met the inclusion criteria. Both medium to longer-term multi-component exercise of moderate to high intensity, and, group cognitive stimulation consistently show benefits. There is not sufficient evidence to determine whether psychological or social interventions might improve either mood or behaviour due to the heterogeneity of the studies and interventions included in the reviews.

spacer-3440186_1920

Conclusion: There is good evidence that multi-component exercise with sufficient intensity improves global physical and cognitive functions and activities of daily living skills. There is also good evidence that group-based cognitive stimulation improves cognitive functions, social interaction and quality of life. This synthesis also highlights the potential importance of group activities to improve social integration for people with dementia. Future research should investigate longer-term specific outcomes, consider the severity and types of dementia, and investigate mechanisms of change.

Full document: Psychosocial interventions for people with dementia: a synthesis of systematic reviews

A treatment for sleep disorders in dementia?

This paper investigates the feasibility and acceptability of a six-session non-pharmacological therapy for people with dementia who have disturbed sleep.  The authors conclude that the ‘DREAMS-START’ intervention for sleep disorders in dementia is both feasible and acceptable | International Psychogeriatrics | via The Mental Elf

In people with dementia, symptoms such as agitation and inappropriate behaviour are fairly well known for being difficult to cope with. What is less well known is that people with dementia often sleep badly. They may wander, putting themselves at risk, and being awake at night then tends to make them sleepy during the day. This sleep disruption can cause a lot of stress for their carers.

Available treatments for this problem do not appear to be very effective. The current study tests a new intervention called DREAMS-START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives), which is delivered to carers over six sessions to help them cope with and improve sleep problems.

bed-731162_1920 (1)

Abstract

Background:40% of people with dementia have disturbed sleep but there are currently no known effective treatments. Studies of sleep hygiene and light therapy have not been powered to indicate feasibility and acceptability and have shown 40–50% retention. We tested the feasibility and acceptability of a six-session manualized evidence-based non-pharmacological therapy; Dementia RElAted Manual for Sleep; STrAtegies for RelaTives (DREAMS-START) for sleep disturbance in people with dementia.

Methods:

We conducted a parallel, two-armed, single-blind randomized trial and randomized 2:1 to intervention: Treatment as Usual. Eligible participants had dementia and sleep disturbances and a family carer and were recruited from two London memory services and Join Dementia Research. Participants wore an actiwatch for two weeks pre-randomization. Trained, clinically supervised psychology graduates delivered DREAMS-START to carers randomized to intervention; covering Understanding sleep and dementia; Making a plan (incorporating actiwatch information, light exposure using a light box); Daytime activity and routine; Difficult night-time behaviors; Taking care of your own (carer’s) sleep; and What works? Strategies for the future. Carers kept their manual, light box, and relaxation recordings post-intervention. Outcome assessment was masked to allocation. The co-primary outcomes were feasibility and acceptability.

Results:

In total, 63 out of 95 eligible referrals consented  62 were randomized, and 37 out of 42  adhered to the intervention.

Conclusions:

Psychosocial interventions for people with dementia and anxiety or depression

Review finds psychosocial interventions to be effective at reducing symptoms of depression or anxiety in people with dementia experiencing these symptoms | Aging & Mental Health

Abstract walking-69708_1280
Objectives:
Assess the effectiveness of psychosocial interventions for depression and anxiety in people with dementia (PWD) or mild cognitive impairment (MCI).

Method:
OvidMedline, PsychInfo and Embase were searched for studies on the 5th August 2017. The efficacy of the studies was estimated using meta-analyses.

 

Results:
Eight RCTs were included. No RCTs were identified for people with MCI. Four RCTs found that psychosocial interventions (multicomponent intervention, Tai Chi, problem adaptation therapy and exercise/walking) were effective at reducing symptoms of depression in PWD who were depressed. One study (Tai Chi) found that these reductions were no longer evident at six-month follow-up. Another study, not included in the meta-analyses, found that pleasant events behaviour therapy and problem solving behaviour therapy improved depression symptoms and this effect remained significant at follow-up. Three RCTs found that psychosocial interventions (music therapy and cognitive behavioural therapy (CBT)) reduced symptoms of anxiety in PWD who were anxious. Evidence from two of these RCTs (music therapy and CBT) showed that these improvements were evident at three to six-month follow-up.

Conclusion:
The identified psychosocial interventions are effective at reducing symptoms of depression or anxiety in PWD experiencing these symptoms. This review is limited by the quality of studies, small sample sizes and the heterogeneity of the interventions, therefore high quality studies with larger sample sizes are required to test the efficacy of specific interventions such as CBT.

Full reference:  Noone, D. et al. | Meta-analysis of psychosocial interventions for people with dementia and anxiety or depressionAging & Mental Health | published online 17 Oct 2018

Management of behavioral and psychological symptoms in people with Alzheimer’s disease

Kales, H. et al. | Management of behavioral and psychological symptoms in people with Alzheimer’s disease: an international Delphi consensus | Published online: August 2018

Objectives:
Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer’s disease (AD) overall, as well as specifically for agitation and psychosis.

Design:
International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process.

Settings:
2015 International Psychogeriatric Association meeting.

Participants:
Expert panel comprised of 11 international members with clinical and research expertise in BPSD management.

Results:
Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin.

Conclusions:
This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

The views of care home staff in relation to experiencing and managing behaviour that challenges in dementia

Aim: To determine the views of care home (CH) staff in relation to experiencing and managing behaviour that challenges (BtC) in dementia and their experiences of training.

Method: Cross-sectional survey using a self-report questionnaire, distributed to staff employed in a 20% sample of all registered dementia-specialist CHs in England, either by postal or direct distribution.

Results: Questionnaires were returned from 352 care staff (25%), representing 5% of all dementia-specialist CHs, half were CH without nursing. Respondents estimated caring for 14,585 residents, 9,361 with dementia and 5,258 with BtC. 30.2% of residents with dementia were estimated as being prescribed a medicine to control BtC. BtC reported as experienced by most respondents were: shouting (96.6%), verbal aggression (96.3%) and physical aggression (95.7%), with physical aggression viewed as most difficult to manage. Top behaviours experienced every shift were: wandering (77.8%), perseveration (68.2%) and restlessness (68.2%).

Approaches such as assessing residents, knowing them and treating them as individuals, identifying triggers, having time for them and using an appropriate style of communication, were viewed as key to managing BtC, rather than guideline-specific interventions such as massage, aromatherapy and animal-assisted therapy.

Only 38% agreed/strongly agreed medicines were useful to control BtC, which was related to the extent to which they were prescribed. Training was available, but variable in quality with on-line training being least useful and on-the job training most desirable.

Conclusion: BtC are commonly and frequently experienced by care staff, who consider individual approaches, having time and good communication are key to successful management.

Full reference:
Charlotte Mallon, Janet Krska & Shivaun Gammie | 2018 | Views and experiences of care home staff on managing behaviours that challenge in dementia: a national survey in England |  Aging & Mental Health |  Published online: 25 May 2018

‘Exergaming’ may help those at risk of Alzheimer’s or related dementias

Older adults with mild cognitive impairment (MCI) showed significant improvement with certain complex thinking and memory skills after exergaming (video games that also require physical exercise) | Frontiers in Aging Neuroscience | via ScienceDaily

minecraft-655158_1280

The results of a new study could encourage health care providers to pursue or prescribe exergames (video games that also require physical exercise) in hopes of slowing the debilitating effects of those with MCI, sometimes a stage between normal brain aging and dementia.

Previously published research had found that seniors who exercise using the features of interactive video games experienced greater cognitive health benefits than those who rely on traditional exercise alone.

For the latest study, researchers wanted to target older adults diagnosed with or at risk for MCI.  Researchers initially enrolled more than 100 seniors for the study. Over six months, 14 (evenly split between men and women) persisted with regular exergaming. The average age was 78.

The first group of seven was assigned to pedal along a scenic virtual reality bike path several times a week. The second group was given a more challenging task for the brain: pedal while playing a video game that included chasing dragons and collecting coins.

The results were compared against data collected from a separate group of eight seniors who played video games on a laptop but did not pedal, and also a group from the previous research who only rode a traditional stationary bike with no gaming component.

At the end of the randomized clinical trial, participants in both the group that pedaled along a virtual bike path and those that chased dragons and collected coins experienced significantly better executive function, which controls, in part, multi-tasking and decision making.

Benefits for both groups were also seen for verbal memory and physical function, suggesting it may be worth the effort for seniors to incorporate exergaming into a daily exercise regime.

The authors acknowledged that further research with a larger sample size is needed to confirm the team’s findings.  In the meantime, the research suggests benefits of exercising while also stimulating the brain with some mental challenge, such as navigating a scenic bike path or interactively playing a video game.

Full story at ScienceDaily

Full reference: Anderson-Hanley, C . et al. The Aerobic and Cognitive Exercise Study (ACES) for Community-Dwelling Older Adults With or At-Risk for Mild Cognitive Impairment (MCI): Neuropsychological, Neurobiological and Neuroimaging Outcomes of a Randomized Clinical TrialFrontiers in Aging Neuroscience, 2018; 10

 

15 years of dementia treatment in 15 papers

Age and Ageing journal has published a free online collection of 15 papers to provide an update on the advances of pharmacological and non-pharmacological interventions in dementia over the last 15 years.

age
Image source: academic.oup.com

The published studies reflect the efficacy of the current anti-dementia treatments, preventive treatments of cardio and cerebrovascular incidents known to be risk factors for dementia, alongside the use of antidepressant medication and non-pharmacological interventions for treatment of behavioural and psychopathological symptoms of dementia. We also address the future preventative steps and therapeutic strategies currently in development to combat the devastating consequences of dementia.

 

These papers are all free to read, download and share from the Age and Ageing journal website. The full collection can be viewed here, or individual papers accessed below.

Currently available anti-dementia treatments

Non-pharmacological interventions

Management of vascular risk factors for dementia

Drug use in people with dementia