Bob Woods

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.

Is exercise effective in promoting mental well-being in older age? A systematic review.

Background: Promoting the mental well-being of older people has been neglected. Aim: To examine the clinical and cost-effectiveness of exercise and physical activity interventions on mental well-being in people aged 65+. Design: Systematic review, meta-analysis, economic model. Methods: Reports published in English, identified by searching 25 databases, 11 websites and references lists of systematic reviews. Eligible studies were those with a comparison or control group or offering qualitative evidence; exercise and physical activity interventions for people aged 65 and above living at home, in the community, in supported housing or in residential care homes; including outcome measures of mental well-being, not simply measures of depression or anxiety. Low-quality studies were excluded from the data synthesis. Results: An overall effect of exercise on mental well-being was found (standardised effect size = 0.27; CI = 0.14–0.40). The included interventions were designed for older people, targeted those who are sedentary and delivered in a community setting, primarily through a group-based approach led by trained leaders. As a minimum, the evidence would suggest two exercise sessions per week, each of 45 min duration. There is some indication that exercise can also improve the mental well-being of frail elders. Economic evidence indicated incremental cost-effectiveness ratios (compared with minimal intervention) of £7300 and £12,100 per quality adjusted life year gained for community-based walking and exercise programmes, respectively. Conclusions: Mental well-being in later life is modifiable through exercise and physical activity. To generalise the findings, there is a need for more evidence of effectiveness from older people in the UK.

The impact of the quality of relationship on the experiences and wellbeing of caregivers of people with dementia: A systematic review

Background: Relatively little attention has been given to the effects of caregiving context on the experience of family members providing care for a person with dementia. This review aims to examine the impact of caregiving on the quality of the relationship between caregiver and care-recipient and the impact of the quality of the relationship between the caregiver and care-recipient on the caregivers and care-recipients wellbeing. Methods: This was a systematic review. Fifteen quantitative studies were identified that examined the quality of the relationship between caregivers and care-recipients who had dementia, meeting the criterion of using a measure of relationship quality beyond a single item. Results: The findings show that caregiving can have an impact on the quality of the relationship between caregiver and care-recipient. In addition, pre-caregiving and current relationship quality appear to have an impact on caregivers wellbeing. The care-recipients needs for help with activities of daily living and level of behavioural problems were found to influence the caregivers perceptions of relationship quality. Conclusions: Future research should examine both current and pre-caregiving relationship quality. A better understanding of the role of relationship quality in determining the outcomes of caregiving will aid the development of more effective interventions for caregivers.

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.

Handbook of the clinical psychology of ageing

THE PSYCHOLOGY OF AGEING: Intellectual Change in Late Life Memory and Learning Language: Speed of Processing Cognitive Changes in Real Life Life-Span Development Retirement Bereavement and Attitudes to Death Sexual Functioning PSYCHOLOGICAL DISORDERS IN OLDER PEOPLE: Functional Disorders Life Events and Social Support: Health and Adjustment Organic Disorders The Neuropsychology of Alzheimers Disease and Other Dementias A Dialectical Framework for Dementia The Psychology of Sub-Cortical Dementias Psychological Aspects of Stroke THE CLINICAL CONTEXT: Community Care - A Psychological Framework The Psychology of Care-Giving Institutional Care - A Systems Approach Normalization - for Elderly People? ASSESSMENT OF THE OLDER PERSON: Neuropsychological Assessment Assessment of Adjustment and Behaviour and the Environment Tests - their Uses and Limitations TREATMENT APPROACHES: Cognitive Behavioural Therapy Psychodynamic Approaches Family Therapy RO, Reminiscence and Validation - Where Next? Challenging Behaviour - A Psychological Approach Working with Carers Working to Change the Institution.

Psychosocial interventions in dementia care research: the INTERDEM manifesto.

Dementia is a biomedical, psychological and societal disability, which poses complex challenges that are different to those of many other disabilities. As a global health problem, it takes a heavy toll on people, society and the economy. Alzheimer’s Disease International, using detailed population-based studies of the prevalence of dementia in different world regions (http://www.alz.co.uk/adi/pdf/prevalence.pdf), estimates that there are currently 30 million people with dementia worldwide, with 4.6 million new cases annually and projections for over 100 million affected people by 2050. As the population ages, the full costs will also escalate, thus making dementia an international priority. In 2008, during his term of EU presidency, French President Nicolas Sarkozy called for prioritising dementia and the development of a European-wide Alzheimer’s plan and the EU Council of Ministers has also called for collaborative action on Alzheimer’s disease research. As a follow-up to the October 2008 conference ‘The fight against Alzheimer’s disease’ organised by the French EU Presidency, and in line with the 2009 Communication from the European Commission on ‘A European initiative on Alzheimer’s disease and other dementias’, the Belgian Presidency of the EU has, from July 2010, initiated a forum to exchange best practices on societal responses to dementia. However, despite two decades of intensive research in Alzheimer’s disease and an active strategy for the recognition and monitoring of the pre-dementia stages (see Knopman et al., 2001, for the American Association of Neurology practice parameter), we are still some way away from a cure or a treatment which can prevent the disorder from worsening or significantly influence its course. Even if curative drug treatments were available, it is likely that the costs of these would be prohibitive, particularly for many developing countries at a time when the prevalence of dementia itself is set to increase in line with the escalating numbers of older people. There is a growing interest in psychosocial interventions in dementia care, but few have reached the stage of rigorous evaluation and even fewer have been widely implemented. In Europe, the diversity of languages and cultures act as an obstacle for developing, testing and implementing evidence-based psychosocial interventions. However, if psychosocial interventions have positive and costeffective outcomes on cognition and quality of life and on rates of institutionalisation, there is potential for dissemination and wider implementation through written materials or manuals detailing intervention protocols. This is particularly relevant for developing countries, where staff can be trained to deliver interventions in settings where access to the anti-dementia drugs is poor or non-existent. The need for a rapid and substantial increase in the quantity and quality of psychosocial research in dementia care has therefore never been more urgent.

The value of personalized psychosocial interventions to address behavioral and psychological symptoms in people with dementia living in care home settings: a systematic review

BACKGROUND Several important systematic reviews and meta-analyses focusing on psychosocial interventions have been undertaken in the last decade. However, they have not focused specifically on the treatment of individual behavioral and psychological symptoms of dementia (BPSD) with personalized interventions. This updated systematic review will focus on studies reporting the effect of personalized psychosocial interventions on key BPSD in care homes. METHODS Systematic review of the evidence for psychosocial interventions for BPSD, focusing on papers published between 2000 and 2012. All care home and nursing home studies including individual and cluster randomized controlled trials (RCTs) and pre-/post-test studies with control conditions were included. RESULTS 641 studies were identified, of which 40 fulfilled inclusion and exclusion criteria. There was good evidence to support the value of personalized pleasant activities with and without social interaction for the treatment of agitation, and reminiscence therapy to improve mood. The evidence for other therapies was more limited. CONCLUSIONS There is a growing body of evidence indicating specific effects of different personalized psychosocial interventions on individual BPSD and mood outcomes.

The impact of individual reminiscence therapy for people with dementia: systematic review.

This systematic review aims to review the potential psychosocial benefits of individual reminiscence therapy for people with dementia. Five randomized controlled trials were identified. All were carried out in nursing or care homes, and several different approaches were represented. The studies reported some immediate and longer-term psychosocial benefits to people with dementia of individual reminiscence work, where this involved a life review process or personalized, specific reminiscence work. These benefits included mood, well-being and aspects of cognitive function. There was no evidence that the use of general reminiscence materials was associated with psychosocial benefits. The use of life story books and multimedia alternatives, with or without an associated life review process, does appear to be worth pursuing from both clinical and research perspectives.

Cognitive training and cognitive rehabilitation for persons with mild to moderate dementia of the Alzheimer's or vascular type: a review.

Cognitive impairments, and particularly memory deficits, are a defining feature of the early stages of Alzheimers disease and vascular dementia. Interventions that target these cognitive deficits and the associated difficulties with activities of daily living are the subject of ever-growing interest. Cognitive training and cognitive rehabilitation are specific forms of non-pharmacological intervention to address cognitive and non-cognitive outcomes. The present review is an abridged version of a Cochrane Review and aims to systematically evaluate the evidence for these forms of intervention in people with mild Alzheimers disease or vascular dementia. Randomized controlled trials (RCTs), published in English, comparing cognitive rehabilitation or cognitive training interventions with control conditions and reporting relevant outcomes for the person with dementia or the family caregiver (or both), were considered for inclusion. Eleven RCTs reporting cognitive training interventions were included in the review. A large number of measures were used in the different studies, and meta-analysis could be conducted for several primary and secondary outcomes of interest. Several outcomes were not measured in any of the studies. Overall estimates of the treatment effect were calculated by using a fixed-effects model, and statistical heterogeneity was measured by using a standard chi-squared statistic. One RCT of cognitive rehabilitation was identified, allowing the examination of effect sizes, but no meta-analysis could be conducted. Cognitive training was not associated with positive or negative effects in relation to any of the reported outcomes. The overall quality of the trials was low to moderate. The single RCT of cognitive rehabilitation found promising results in relation to some patient and caregiver outcomes and was generally of high quality. The available evidence regarding cognitive training remains limited, and the quality of the evidence needs to improve. However, there is still no indication of any significant benefits from cognitive training. Trial reports indicate that some gains resulting from intervention may not be captured adequately by available standardized outcome measures. The results of the single RCT of cognitive rehabilitation show promise but are preliminary in nature. Further well-designed studies of cognitive training and cognitive rehabilitation are required to provide more definitive evidence. Researchers should describe and classify their interventions appropriately by using the available terminology.