Elmar Gräßel

Non-Drug Therapies for Dementia: An Overview of the Current Situation with Regard to Proof of Effectiveness

An overview will be presented of music therapy, art therapy, movement therapy and reminiscence therapy, memory training, reality orientation, validation therapy, self-maintenance therapy, behaviour therapy, milieu therapy and staff training. The overview will examine the aims of each, the principles on which procedures are based and the proof of their effectiveness. The principal aim of non-drug therapies is to influence symptomatic dementia beneficially and to improve the abilities remaining to the patient. The potential benefits are usually deduced from studies made without control groups. At the present time, proof of the effectiveness of these therapies is still lacking as controlled, randomized studies have yet to be conducted, and so a fundamental evaluation of the therapeutic benefits of non-drug therapies in the treatment of dementia cannot yet be made.

When home care ends: Changes in the physical health of informal caregivers caring for dementia patients: A longitudinal study

OBJECTIVES: To verify the change in health variables and parameters of health service utilization in a group of active caregivers for older persons with dementia in comparison with former caregivers who had ceased to provide home care for at least 6 months (death of the patient or institutionalized care).

Intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients. Controlled clinical trial with follow-up assessment six months after discharge

Objective: An intensified transition concept between neurological inpatient rehabilitation and home care was investigated for effects on the functional status of stroke patients and the physical and emotional health of their carers. Design: Controlled clinical trial allocating patients to intervention group (intensified transition on ward II) or control group (standard transition on ward I); patients were allocated to whichever ward had a vacancy. Follow-up assessment was carried out six months after discharge. Subjects: Seventy-one patients and their family carers were included, of which nine cases dropped out. Therefore 62 stroke patients with persisting disability and their family carers were available for assessment at follow-up - 33 patients in the intervention group, 29 patients in the control group. Intervention: The intensified transition concept consisted of therapeutic weekend care, bedside teaching and structured information for relatives during the second phase of the rehabilitation. Main measures: Patients were assessed with the Barthel Index, Functional Independence Measure, Ashworth Spastic Scale, Frenchay Arm Test, and Timed Up and Go Test. The carers completed SF-36, and were assessed using the Giessen Symptom List, Depression Scale and Burden Scale for Family Caregivers. Results: The intensified transition did not lead to significant change in the functional status of the patients or in the physical and emotional health of the family carers. Within the first four weeks after discharge, the patients in the intervention group had fewer new illnesses. In the observation period the use of outpatient care services was more frequent in the intervention group than in the control group. Conclusion: Even though there are few differences of moderate intensity between the two groups the intensified transition programme does not affect either the functional status of the stroke patients or the health of the carers.

Depression and bulbar involvement in amyotrophic lateral sclerosis

OBJECTIVE: Patients with amyotrophic lateral sclerosis (ALS) often develop depressive symptoms. Little is known of the factors that predict or influence depression in ALS patients. PATIENTS AND METHODS: In 41 ALS patients we compared a self-rating depression scale with the ALS Functional Rating Scale (ALS-FRS), duration of disease, age, sex, education and participation in a self-help group. RESULTS: There was no significant relation between the total ALS-FRS score and the self-rating depression scale. In contrast, we found a significant correlation between the swallowing (r=−0.453; P=0.003) and breathing (r=−0.333; P=0.033) items of the ALS-FRS and the depressive scale. Depressive symptoms were negatively correlated with the duration of the disease (r=−0.377; P=0.016); there was no influence of age or sex. CONCLUSION: We found no evidence for a direct association between the loss of physical ability in general and depression, but for a decrease of depressive symptoms in relation to the length of time since diagnosis. Therefore, depressive symptoms in ALS patients seem to occur mainly as a depressive reaction following the communication of the diagnosis. In addition, patients with bulbar and respiratory symptoms should carefully be screened for depressive symptoms.

A valid instrument for measuring informal care time for people with dementia

An economic evaluation of dementia‐related interventions from a societal perspective should take account of informal caregiving. We assessed informal caregiving time and report our findings on the validity and stability of our results.

Effects of general practitioner training and family support services on the care of home-dwelling dementia patients - Results of a controlled cluster-randomized study

BackgroundMore than 90% of dementia patients are cared for by their general practitioners, who are decisively involved in the diagnosis, therapy and recommendation of support services. Objective: To test whether special training of general practitioners alters the care of dementia patients through their systematic recommendation of caregiver counseling and support groups.Method129 general practitioners enrolled 390 dementia patients and their informal caregivers in a prospective, three-arm cluster-randomized 2-year study. Arm A constituted usual care, in Arm B and C support groups and caregiver counseling (in Arm B one year after baseline, in Arm C at baseline) were recommended by the general practitioners. The general practitioners received arm-specific training. Diagnostic and therapeutic behavior of physicians was recorded at baseline. Informal caregivers were questioned in follow-up after 2 years about the utilization of support services.ResultsThe diagnostic behavior of the general practitioners conforms to relevant guidelines. The procedure in newly-diagnosed patients does not differ from previously diagnosed patients with the exception of the rate of referral to a specialist. About one-third of the newly-diagnosed dementia patients are given an anti-dementia drug. The utilization of support groups and counseling increased five- and fourfold, respectively. Utilization of other support services remained low (< 10%), with the exception of home nursing and institutional short-term nursing.ConclusionTrained general practitioners usually act in conformity with guidelines with respect to diagnosing dementia, and partly in conformity with the guidelines with respect to recommended drug therapy. Recommendations of support services for informal caregivers by the general practitioner are successful. They result in a marked increase in the utilization rate for the recommended services compared to offers which are not recommended by the general practitioner.Trial registrationISRCTN68329593

Somatic symptoms and caregiving strain among family caregivers of older patients with progressive nursing needs

A study of 120 family caregivers caring for relatives with nursing needs caused by different diseases was carried out to measure the extent of somatic symptoms among the caregivers (Giessen Symptom List, (GSL)) and the degree of perceived burden (Burden Scale for Family Caregivers, (BSFC)). With the exception of caregivers caring for patients with internal-medical geriatric diseases, the extent of the somatic symptoms observed amongst the caregivers was significantly higher than the symptoms in their corresponding average age groups. This was true of all the symptom complexes examined. In addition to heart and stomach complaints, especially the number of cases of physical exhaustion and aching limbs was raised. The extent of somatic symptoms among male caregivers was not above-average. The correlation between the extent of the somatic symptoms and the extent of the perceived burden was highly significant.

Dementia care initiative in primary practice – study protocol of a cluster randomized trial on dementia management in a general practice setting

BackgroundCurrent guidelines for dementia care recommend the combination of drug therapy with non-pharmaceutical measures like counselling and social support. However, the scientific evidence concerning non-pharmaceutical interventions for dementia patients and their informal caregivers remains inconclusive. Targets of modern comprehensive dementia care are to enable patients to live at home as long and as independent as possible and to reduce the burden of caregivers. The objective of the study is to compare a complex intervention including caregiver support groups and counselling against usual care in terms of time to nursing home placement. In this paper the study protocol is described.Methods/DesignThe IDA (Initiative Demenzversorgung in der Allgemeinmedizin) project is designed as a three armed cluster-randomized trial where dementia patients and their informal caregivers are recruited by general practitioners. Patients in the study region of Middle Franconia, Germany, are included if they have mild or moderate dementia, are at least 65 years old, and are members of the German AOK (Allgemeine Ortskrankenkasse) sickness fund. In the control group patients receive regular treatment, whereas in the two intervention groups general practitioners participate in a training course in evidence based dementia treatment, recommend support groups and offer counseling to the family caregivers either beginning at baseline or after the 1-year follow-up. The study recruitment and follow-up took place from July 2005 to January 2009. 303 general practitioners were randomized of which 129 recruited a total of 390 patients. Time to nursing home admission within the two year intervention and follow-up period is the primary endpoint. Secondary endpoints are cognitive status, activities of daily living, burden of care giving as well as healthcare costs. For an economic analysis from the societal perspective, data are collected from caregivers as well as by the use of routine data from statutory health insurance and long-term care insurance.DiscussionFrom a public health perspective, the IDA trial is expected to lead to evidence based results on the community effectiveness of non-pharmaceutical support measures for dementia patients and their caregivers in the primary care sector. For health policy makers it is necessary to make their decisions about financing new services based on strong knowledge about the acceptance of measures in the population and their cost-effectiveness.Trial registrationISRCTN68329593

Support groups for dementia caregivers--predictors for utilisation and expected quality from a family caregiver's point of view: a questionnaire survey part I*.

BackgroundSupport groups have proved to be effective in reducing the burden on family caregivers of dementia patients. Nevertheless, little is known about the factors that influence utilisation or quality expectations of family caregivers. These questions are addressed in the following paper.MethodsThe cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in Germany. Qualitative and quantitative data from 404 caregivers were analysed using content analysis and binary logistic regression analysis.ResultsThe only significant predictor for utilisation is assessing how helpful support groups are for the individual care situation. Family caregivers all agree that psycho-educative orientation is a priority requirement.ConclusionsIn order to increase the rate of utilisation, family caregivers must be convinced of the relevant advantages of using support groups. Support groups which offer an exchange of experiences, open discussion, information and advice meet the requirements of family caregivers.

Temporary Institutional Respite in Dementia Cases: Who Utilizes This Form of Respite Care and What Effect Does It Have?

In the studies on the effects of temporary institutional respite (TIR) published to date, a slight reduction of subjective burden has been established. The hope that this form of respite care might have a positive effect on the activities of daily living or on the health of the care recipients has not yet been confirmed. A considerable deficit in the methodology applied might be a reason for this. There is no denying the fact that there is a clear need for respite services, particularly because every seventh person providing care for a dementia patient requiring personal care belongs to a high-risk group that is characterized by serious reduction in his or her physical health and psychological well-being. TIR is primarily utilized by adult child caregivers (daughters and daughters-in-law) affected by high subjective burden who are providing care for dementia patients with extensive nursing needs.