Aimee Spector

Nonpharmacological Therapies in Alzheimer’s Disease: A Systematic Review of Efficacy

Introduction: Nonpharmacological therapies (NPTs) can improve the quality of life (QoL) of people with Alzheimer’s disease (AD) and their carers. The objective of this study was to evaluate the best evidence on the effects of NPTs in AD and related disorders (ADRD) by performing a systematic review and meta-analysis of the entire field. Methods: Existing reviews and major electronic databases were searched for randomized controlled trials (RCTs). The deadline for study inclusion was September 15, 2008. Intervention categories and outcome domains were predefined by consensus. Two researchers working together detected 1,313 candidate studies of which 179 RCTs belonging to 26 intervention categories were selected. Cognitive deterioration had to be documented in all participants, and degenerative etiology (indicating dementia) had to be present or presumed in at least 80% of the subjects. Evidence tables, meta-analysis and summaries of results were elaborated by the first author and reviewed by author subgroups. Methods for rating level of evidence and grading practice recommendations were adapted from the Oxford Center for Evidence-Based Medicine. Results: Grade A treatment recommendation was achieved for institutionalization delay (multicomponent interventions for the caregiver, CG). Grade B recommendation was reached for the person with dementia (PWD) for: improvement in cognition (cognitive training, cognitive stimulation, multicomponent interventions for the PWD); activities of daily living (ADL) (ADL training, multicomponent interventions for the PWD); behavior (cognitive stimulation, multicomponent interventions for the PWD, behavioral interventions, professional CG training); mood (multicomponent interventions for the PWD); QoL (multicomponent interventions for PWD and CG) and restraint prevention (professional CG training); for the CG, grade B was also reached for: CG mood (CG education, CG support, multicomponent interventions for the CG); CG psychological well-being (cognitive stimulation, multicomponent interventions for the CG); CG QoL (multicomponent interventions for PWD and CG). Conclusion: NPTs emerge as a useful, versatile and potentially cost-effective approach to improve outcomes and QoL in ADRD for both the PWD and CG.

Whose quality of life is it anyway? The validity and reliability of the Quality of Life-Alzheimer's Disease (QoL-AD) scale

Quality of life (QoL) is becoming an increasingly used outcome measure in both clinical practice and research. There are now more than 1000 scales available to measure QoL, and it is important that they are assessed for reliability and validity. This study aims to assess the reliability and validity of the Quality of Life-Alzheimers Disease (QoL-AD) scale, which is dementia specific and brief and uses the patients own responses. Two separate samples of people with dementia (sample 1, n = 60; sample 2, n = 201) were assessed. Five focus groups were conducted involving both people with dementia and their caregivers; the focus groups showed that people with dementia had higher hopes for their QoL than their caregivers did for them. Questionnaires about the scale were completed by 71 health care professionals working with people with dementia. The scale was found to have good content validity with no additional items required and all items necessary. It also correlated well with the Dementia Quality of Life scale (0.69) and with the Euroqol-5D scale (0.54), indicating good criterion concurrent validity. Construct validity was also good with the principal components analysis showing all 13 items of the QoL-AD loaded on component 1. Interrater reliability was excellent with all Cohens kappa values >0.70. Internal consistency was excellent with a Cronbachs alpha coefficient of 0.82. Some people with severe dementia and a Mini-Mental State Examination score as low as 3 were able to satisfactorily complete the QoL-AD. The QoL-AD has very good psychometric properties and can be completed with people with a wide range of severity of dementia.

Improved quality of life and cognitive stimulation therapy in dementia

Quality of life (QoL) is now seen as a key outcome in many aspects of dementia care. In a recent randomized controlled trial of Cognitive Stimulation Therapy (CST) groups, significant improvements in self-reported QoL were identified as well as changes in cognitive function. This further analysis of results from the trial examines whether the changes in these two domains occurred independently, perhaps for different reasons, or whether the effect of treatment on QoL was mediated by the changes in cognition. In all, 201 people with dementia living in residential homes or attending day centres were assessed using the Quality of Life-Alzheimers Disease (QOL-AD) scale and a range of measures of cognition, dementia level, mood, dependency and communication. Participants were randomized to receive an intervention programme of CST or to receive treatment as usual. The QoL-AD and other measures were repeated eight weeks later. At baseline, higher QoL in dementia was significantly correlated with lower levels of dependency and depression, but not with cognitive function or dementia severity. Improvement in quality of life was associated with being female, low quality of life at baseline, reduced depression and increased cognitive function. Changes in cognitive function mediated the effects of treatment in improving QoL. These results suggest that whilst QoL in dementia appears to be independent of level of cognitive function, interventions aimed at improving cognitive function can, nonetheless, have a direct effect on QoL.

Can reality orientation be rehabilitated? Development and piloting of an evidence-based programme of cognition-based therapies for people with dementia

This study describes the development and implementation of a programme of cognition-based therapies for dementia. The programme was designed by distilling the evidence of the effectiveness of Reality Orientation and related approaches, following a broad-based systematic review. The most beneficial elements identified from previous studies were extracted and incorporated into the programme, using the expertise of specialists in the field. The programme comprised of 15 45-min, twice weekly sessions. It ran in one day centre and three residential homes, involving 27 people with dementia (17 treatment and 10 control subjects). The results of the pilot study showed positive trends in cognition, and trends towards reduced depression and anxiety following treatment. No negative effects were identified. We discuss how the outcomes of the pilot study were used to modify the programme, which now has a stronger cognitive element. This refined programme is currently being tested as part of a large multicentre, randomised controlled trial.

Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials

Cognitive stimulation is a psychological intervention widely used in dementia care, which offers a range of activities for people with dementia and provides general stimulation of cognitive abilities. This systematic review evaluates the effectiveness of cognitive stimulation in dementia. The review included studies from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, called ALOIS. This yielded ninety-four studies, of which fifteen were randomised controlled trials meeting the inclusion criteria. The analysis included 718 subjects (407 receiving cognitive stimulation and 311 in control groups). Results were subjected to a meta-analysis. A consistent significant benefit to cognitive function was identified following treatment and the benefits appeared to be over and above any medication effects. This remained evident at follow-up up to three months after the end of treatment. In secondary analyses, with smaller total sample sizes, significant benefits were also noted for quality of life and well-being, and on staff ratings of communication and social interaction. No differences in relation to mood, activities of daily living or challenging behaviour were noted. There is consistent evidence that cognitive stimulation interventions benefit cognitive function and aspects of well-being. Cognitive stimulation should be made more widely available in dementia care.

The impact of young onset dementia on the family: a literature review.

BACKGROUND The needs of younger people with dementia have become increasingly recognized in service development. However, little is known about the impact of a diagnosis of young onset dementia on people aged under 65 years and their families. This paper reviews the literature on the experiences of younger people with dementia and their families in the U.K., and outcomes for carers. METHODS Twenty-six studies, encompassing a variety of themes concerning this population, were reviewed following a systematic literature search. RESULTS Results are divided into the impact on the individual and the impact on the family, specifically carer outcomes and the impact on children. CONCLUSIONS The studies reviewed reveal a number of negative outcomes for the individual and carers, and highlight the need for further research.

Cognitive Stimulation Therapy (CST): effects on different areas of cognitive function for people with dementia

There is good evidence indicating that group Cognitive Stimulation Therapy (CST) leads to generalised cognitive benefits for people with dementia. However, little is known about whether some aspects of cognition might change more than others and why.

Cognitive stimulation for the treatment of Alzheimer’s disease

In recent years, there has been an increase in the recognition and use of psychosocial interventions for dementia. This has coincided with an increase in high-quality research in the area, and restrictions in the use of drug therapies for Alzheimer’s disease in the UK. Cognitive stimulation therapy (CST) is a brief group treatment for people with mild-to-moderate dementia, based on the theoretical concepts of reality orientation and cognitive stimulation. It involves 14 sessions of themed activities which typically run twice a week over a 7-week period. A multicenter, randomized controlled trial showed significant benefits in cognition and participant-rated quality of life when comparing CST versus no treatment. These benefits in cognition were comparable to those gained through medication, and CST also proved to be cost-effective. Influenced by this research, the latest guidelines released by NICE recommended cognitive stimulation only as an intervention for treating the cognitive symptoms of dementia. This perspective describes how CST was developed and evaluated, its use in clinical settings and issues for future investigation, such as individualized CST.

A systematic review of staff training interventions to reduce the behavioural and psychological symptoms of dementia

Behavioural and psychological symptoms of dementia (BPSD) are highly prevalent and problematic in care settings. Given the limited effectiveness of medical treatments, training care staff to understand and manage these symptoms is essential for the safety and quality of life of people with dementia. This review evaluated the effectiveness of staff training interventions for reducing BPSD. A systematic literature search identified 273 studies. Twenty studies, published between 1998 and 2010, were found to meet the inclusion criteria. Overall, there was some evidence that staff training interventions can impact on BPSD: twelve studies resulted in significant symptom reductions, four studies found positive trends and four studies found no impact on symptoms. No links were found between the theoretical orientation of training programmes and their effectiveness. Training was also found to impact on the way staff behaved towards residents. A quality screening, using pre-specified criteria, revealed numerous methodological weaknesses and many studies did not adhere to the recommended guidelines for the conduct of cluster randomised controlled trials. There is an urgent need for more high quality research and evidence-based practice in BPSD.

Using a biopsychosocial model of dementia as a tool to guide clinical practice

BACKGROUND Over the years, a number of non-medical and psychosocial explanations and models of dementia have been proposed, due to the complex nature of the illness. However, there is a need for a more pragmatic, user-friendly model which takes into account the biological, psychological and social processes. METHODS Existing models of dementia were amalgamated into a revised, pragmatic model which aims to increase our understanding of the factors that may lead to improvement or deterioration in dementia and to illustrate the role of psychosocial factors in the context of biological processes. The model suggests that in both psychosocial and biological domains there are fixed factors (aspects which relate to history or risk factors and therefore not amenable to change), tractable factors (aspects which may be amenable to change), and interventions with potential benefit. RESULTS The trajectory of dementia is presented as a process, beginning with aging and ending in death. Both the fixed and the tractable factors may influence the severity of dementia, affecting function, the speed and nature of the deterioration, and the appropriateness and effectiveness of interventions. A working case example is provided, demonstrating how the model may be used by clinicians when assessing the difficulties of an individual with dementia and identifying ways to improve the quality of life and reduce excess disability for that person. CONCLUSIONS This model provides a theoretical framework and an ambitious approach to care in dementia which takes into account positive as well as negative factors. We hope it may become a useful tool for researchers and clinicians to help understand what impacts on individuals with dementia and the most appropriate ways to intervene.