David Lowery

The effect of exercise on behavioral and psychological symptoms of dementia: towards a research agenda.

BACKGROUNDnBehavioral and psychological symptoms of dementia (BPSD) are common and are core symptoms of the condition. They cause considerable distress to the person with dementia and their carers and predict early institutionalization and death. Historically, these symptoms have been managed with anxiolytic and antipsychotic medication. Although potentially effective, such medication has been used too widely and is associated with serious adverse side-effects and increased mortality. Consequently, there is a need to evaluate non-pharmacological therapies for behavioral and psychological symptoms in this population. One such therapy is physical activity, which has widespread health benefits. The aim of this review is to summarize the current findings of the efficacy of physical activity on BPSD.nnnMETHODnPublished articles were identified using electronic and manual searches. Rather than systematically aggregating data, this review adopted a rapid critical interpretive approach to synthesize the literature.nnnRESULTSnExercise appears to be beneficial in reducing some BPSD, especially depressed mood, agitation, and wandering, and may also improve night-time sleep. Evidence of the efficacy of exercise on improving other symptoms such as anxiety, apathy, and repetitive behaviors is currently weak or lacking.nnnCONCLUSIONnThe beneficial effect of exercise type, its duration, and frequency is unclear although some studies suggest that walking for at least 30 minutes, several times a week, may enhance outcome. The methodological shortcomings of current work in this area are substantial. The research and clinical implications of current findings are discussed.

The effect of exercise on behavioural and psychological symptoms of dementia: the EVIDEM-E randomised controlled clinical trial

The objective of this study is to evaluate the effectiveness of a simple dyadic (person with dementia and their main carer) exercise regimen as a therapy for the behavioural and psychological symptoms of dementia.

Subtle Attentional Deficits in the Absence of Dementia Are Associated with an Increased Risk of Post-Operative Delirium

Background: Previously, key studies of the risk profile for post-surgical delirium have focused on general medical and non-elective patients, few have examined elective cohorts. Accurate prediction is imperative for clinical trials and prevention strategies. Aims/Hypothesis: Our hypothesis was that subtle pre-operative impairments of attention will be associated with risk of post-operative delirium. Method: A prospective study evaluating pre- and post-operative neuropsychological performance in older (≧70) consecutive elective admissions for orthopaedic surgery, and free of dementia (n = 100) was initiated in a general medical hospital. Results: Pre-operative attentional deficits were closely associated with delirium. Patients who developed post-surgical delirium had significantly slower mean reaction times (p ≤ 0.011) and greater variability of reaction time (p = 0.017). A 4- to 5-fold increased risk of delirium was observed for people one standard deviation above the sample means on these variables. Conclusions: The present study describes a measurement of attentional performance which could form the basis of a neuropsychological marker of delirium.

Evaluation of exercise on individuals with dementia and their carers: a randomised controlled trial.

BackgroundAlmost all of the 820,000 people in the UK with dementia will experience Behavioural and Psychological Symptoms of Dementia (BPSD). However, research has traditionally focused on treating cognitive symptoms, thus neglecting core clinical symptoms that often have a more profound impact on living with dementia. Recent evidence (Kales et al, 2007; Ballard et al, 2009) indicates that the popular approach to managing BPSD - prescription of anti-psychotic medication - can increase mortality and the risk of stroke in people with dementia as well as impair quality of life and accelerate cognitive decline. Consequently, there is a need to evaluate the impact that non-pharmacological interventions have on BPSD; we believe physical exercise is a particularly promising approach.Methods/DesignWe will carry out a pragmatic, randomised, single-blind controlled trial to evaluate the effectiveness of exercise (planned walking) on the behavioural and psychological symptoms of individuals with dementia. We aim to recruit 146 people with dementia and their carers to be randomized into two groups; one will be trained in a structured, tailored walking programme, while the other will continue with treatment as usual. The primary outcome (BPSD) will be assessed with the Neuropsychiatric Inventory (NPI) along with relevant secondary outcomes at baseline, 6 and 12 weeks.DiscussionDesigning this study has been challenging both ethically and methodologically. In particular to design an intervention that is simple, measurable, safe, non-invasive and enjoyable has been testing and has required a lot of thought. Throughout the design, we have attempted to balance methodological rigour with study feasibility. We will discuss the challenges that were faced and overcome in this paper.Trial RegistrationISRCTN01423159

Quantifying the association between computerised measures of attention and confusion assessment method defined delirium: a prospective study of older orthopaedic surgical patients, free of dementia

To determine whether attentional impairments are reliable neuropsychological markers of delirium.

Subtle deficits of attention after surgery: quantifying indicators of sub syndrome delirium

To determine whether attentional impairments are reliable neuropsychological markers of sub syndrome delirium.

Clinicians as recruiters to dementia trials: lessons from the EVIDEM‐E project

‘Evidenced based interventions in dementia’ (EVIDEM: www.EVIDEM.org.uk) is a 5-year research & development programme aiming to explore, evaluate and improve the quality of community based dementia care (Iliffe et al., 2008). The EVIDEM programme, like most clinical trials, relies on clinicians to recruit participants. Key NHS Stakeholders support was strong for EVIDEM and so we anticipated straightforward recruitment. However, this has not been the case; from a population exceeding 2000 people with dementia, one EVIDEM trial (EVIDEM-E: http://www.evidem.org.uk/projects/evidem-e.htm) recruited 6 participants over 6 months through clinical teams, despite minimal exclusion criteria. Our enquiries suggested that this was due to clinicians not distributing invitations, rather than a lack of interest from people with dementia and their carers. With recruitment alarmingly low and struggling to understand the incongruity between verbal support and limited promotion of the study, we invited team managers, nurses, occupational therapists, physiotherapists and psychologists to a facilitated roundtable discussion on their perceptions of research, impediments to their role as recruiters and ways to enhance recruitment.

Behavioural and Psychological Symptoms of Dementia (BPSD): The Personal and Practical Costs of Dementia

Behavioural and psychological symptoms of dementia (BPSD) are a far too common and disturbing occurrence for people with dementia, their families and those who care for them. The consequences can be not only devastating personally and challenging professionally, but also costly for service providers. In this, the fourth of this series on older peoples mental health services, we describe what BPSD are, what we know about current service provision for this group and the gaps, and how commissioners might approach these issues when developing services for older people with dementia.

Cost-effectiveness of exercise as a therapy for behavioural and psychological symptoms of dementia within the EVIDEM-E randomised controlled trial

Although available evidence is modest, exercise could be beneficial in reducing behavioural and psychological symptoms of dementia. We aim to evaluate the cost‐effectiveness of a dyadic exercise regimen for individuals with dementia and their main carer as therapy for behavioural and psychological symptoms of dementia.

Analysis of Neuron-Specific Enolase and S100B as Biomarkers of Cognitive Decline Following Surgery in Older People

Background/Aims: Post-operative cognitive decline is frequent in older individuals following major surgery; however, biomarkers of this decline are less clearly defined. Methods: Sixty-eight participants over the age of 60 provided blood samples at baseline and 24 h post-surgery. Cognitive decline was measured at baseline and 52 weeks post-surgery using the Cambridge Assessment for Mental Disorder in the Elderly, section B (CAMCOG) score. Plasma levels of neuron-specific enolase (NSE) and S100B were measured by ELISA. Results: Baseline NSE and the change in NSE levels between baseline and 24 h were correlated with the change in CAMCOG score between baseline and 52 weeks. Conclusion: NSE concentrations may be a useful predictor of individuals at risk of more severe long-term cognitive decline.