Erin M. Hubbard

Melatonin and Bright-Light Treatment for Rest–Activity Disruption in Institutionalized Patients with Alzheimer’s Disease

OBJECTIVES: To test whether the addition of melatonin to bright‐light therapy enhances the efficacy in treating rest–activity (circadian) disruption in institutionalized patients with Alzheimers disease (AD).

Effect of morning bright light treatment for rest–activity disruption in institutionalized patients with severe Alzheimer’s disease

BACKGROUND Disturbances in rest-activity rhythm are prominent and disabling symptoms in Alzheimers disease (AD). Nighttime sleep is severely fragmented and daytime activity is disrupted by multiple napping episodes. In most institutional environments, light levels are very low and may not be sufficient to enable the circadian clock to entrain to the 24-hour day. The purpose of this randomized, placebo-controlled, clinical trial was to test the effectiveness of morning bright light therapy in reducing rest-activity (circadian) disruption in institutionalized patients with severe AD. METHOD Subjects (n = 46, mean age 84 years) meeting the NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke--the Alzheimers Disease and Related Disorders Association) AD diagnostic criteria were recruited from two large, skilled nursing facilities in San Francisco, California. The experimental group received one hour (09:30-10:30) of bright light exposure (> or = 2500 lux in gaze direction) Monday through Friday for 10 weeks. The control group received usual indoor light (150-200 lux). Nighttime sleep efficiency, sleep time, wake time and number of awakenings and daytime wake time were assessed using actigraphy. Circadian rhythm parameters were also determined from the actigraphic data using cosinor analysis and nonparametric techniques. Repeated measures analysis of variance (ANOVA) was used to test the primary study hypotheses. RESULTS AND CONCLUSION Although significant improvements were found in subjects with aberrant timing of their rest-activity rhythm, morning bright light exposure did not induce an overall improvement in measures of sleep or the rest-activity in all treated as compared to control subjects. The results indicate that only subjects with the most impaired rest-activity rhythm respond significantly and positively to a brief (one hour) light intervention.

Light treatment for neuropsychiatric behaviors in Alzheimer's disease.

Neuropsychiatric behaviors are common in people with Alzheimers disease (AD) and make both professional and lay caregiving difficult. Light therapy has been somewhat successful in ameliorating disruptive behaviors. This randomized trial tested the effects of morning or afternoon bright light exposure compared with usual indoor light on the presence, frequency, severity, and occupational disruptiveness of neuropsychiatric behaviors in nursing home residents with AD. Light was administered for 1 hr daily (Monday-Friday) for 10 weeks. The Neuropsychiatric Inventory—Nursing Home was used to assess behavior at baseline and end of the intervention. Analyses revealed statistically significant differences between groups on agitation/aggression, depression/dysphoria, aberrant motor behavior, and appetite/eating disorders. The magnitude of change was small and may not represent clinically significant findings. Agitation/aggression and nighttime behaviors commonly occurred and were highly correlated with occupational disruptiveness. Interventions that decrease the presence and/or severity of neuropsychiatric behaviors have the potential to significantly decrease caregiver burden.

Associations of Schizophrenia Symptoms and Neurocognition With Physical Activity in Older Adults With Schizophrenia

Background: Low levels of physical activity contribute to the generally poor physical health of older adults with schizophrenia. The associations linking schizophrenia symptoms, neurocognition, and physical activity are not known. Research is needed to identify the reasons for this population’s lack of adequate physical activity before appropriate interventions can be designed and tested. Design and Methods: In this cross-sectional study, 30 adults aged ≥55 years with schizophrenia were assessed on symptoms (Positive and Negative Syndrome Scale), neurocognition (MATRICS Consensus Cognitive Battery), and physical activity (Sensewear ProArmband). Pearson’s bivariate correlations (two-tailed) and univariate linear regression models were used to test the following hypotheses: (1) more severe schizophrenia symptoms are associated with lower levels of physical activity and (2) more severe neurocognitive deficits are associated with lower levels of physical activity. Results: Higher scores on a speed-of-processing test were associated with more average daily steps (p = .002) and more average daily minutes of moderate physical activity (p = .009). Higher scores on a verbal working memory task were associated with more average daily minutes of moderate physical activity (p = .05). More severe depressive symptoms were associated with more average daily minutes of sedentary activity (p = .03). Conclusion: Physical activity interventions for this population are imperative. In order for a physical activity intervention to be successful, it must include components to enhance cognition and diminish psychiatric symptoms.

“We’re Not Just Sitting on the Periphery”: A Staff Perspective of Physical Activity in Older Adults With Schizophrenia

UNLABELLED Targeted physical activity interventions to improve the poor physical function of older adults with schizophrenia are necessary but currently not available. Given disordered thought processes and institutionalization, it is likely that older adults with schizophrenia have unique barriers and facilitators to physical activity. It is necessary to consider the perspective of the mental health staff about barriers and facilitators to physical activity to design a feasible intervention. PURPOSE OF THIS STUDY To describe the perceptions of mental health staff about barriers and facilitators to engage in physical activities that promote physical function among older adults with schizophrenia. DESIGN AND METHOD We conducted qualitative interviews with 23 mental health staff that care for older adults with schizophrenia. The data were collected and analyzed with grounded theory methodology. RESULTS The participants were interested in promoting physical activity with older adults with schizophrenia. Facilitators and barriers to physical activity identified were mental health, role models and rewards, institutional factors, and safety. IMPLICATIONS In order to design successful physical activity interventions for this population, the intervention may need to be a routine part of the mental health treatment program and patients may need incentives to participate. Staff should be educated that physical activity may provide the dual benefit of physical and mental health treatment.

Characterization of Apathy in Persons with Frontotemporal Dementia and The Impact on Family Caregivers

This study characterized daytime activity and apathy in patients with behavioral variant frontotemporal dementia (bvFTD) and semantic dementia (SD) and their family caregivers. Twenty-two patient-caregiver dyads were enrolled: 13 bvFTD and 9 SD. Data were collected on behavior and movement. Patients and caregivers wore Actiwatches for 2 weeks to record activity. We predicted that bvFTD patients would show greater caregiver report of apathy and less daytime activity compared with patients diagnosed with SD. Patients with bvFTD spent 25% of their day immobile, whereas patients with SD spent 16% of their day inactive. BvFTD caregivers spent 11% of their day immobile and SD caregivers were immobile 9% of their day. Apathy was present in all of the patients with bvFTD and in all but one patient with SD; the severity of apathy was greater in bvFTD compared with SD. Apathy correlated with caregiver emotional distress in both groups. In conclusion, apathy has been defined as a condition of diminished motivation that is difficult to operationalize. Among patients with frontotemporal dementia, apathy was associated with lower levels of activity, greater number of bouts of immobility, and longer immobility bout duration. Apathy and diminished daytime activity appeared to have an impact on the caregiver. Objective measures of behavioral output may help in formulation of a more precise definition of apathy.

Sleep in Persons With Frontotemporal Dementia and Their Family Caregivers

Background:Dementia is associated with disruptions in sleep and sleep quality for patients and their family caregivers. Little is known about the impact of frontotemporal dementia (FTD) on sleep. Objective:The purpose of this study was to characterize sleep in patients with FTD and their family caregivers. Methods:Twenty-two patient–caregiver dyads were enrolled: Thirteen behavioral variant FTD (bvFTD) and nine semantic dementia (SD). Sleep and sleep quality data were collected for 2 weeks using diaries and Actiwatches. Results:Patients with bvFTD and SD spent more time in bed at night compared to their caregivers. Nighttime behaviors were reported more frequently by caregivers for the bvFTD patients and strongly correlated with caregiver distress. Actigraphy data showed normal sleep efficiency and timing of the nighttime sleep period for both patients and their caregivers. Caregivers of patients with bvFTD reported poorer sleep quality compared to the SD caregivers. A greater number of bvFTD caregivers compared to SD reported negative aspects of sleep quality for themselves and used sleep medications more frequently. Conclusion:The clinical manifestations of bvFTD appear to be associated with different and more distressing impacts on the caregiver sleep quality than SD.

“It’s Good for Me”: Physical Activity in Older Adults with Schizophrenia

Physical activity (PA) interventions to improve the physical function of older adults with schizophrenia are necessary but not available. Older adults with schizophrenia may have unique barriers and facilitators to PA. The purpose of this study was to describe the perceptions of older adults with schizophrenia about barriers and facilitators to engage in physical activities that promote physical function. We conducted qualitative interviews with 16 older adults with schizophrenia. Data were collected and analyzed with grounded theory methodology. Participants expressed interest in becoming more physically active for a variety of perceived benefits including psychiatric symptom management and maintenance of basic function. Key barriers and facilitators to PA emerged in five broad categories: Mental Health, No longer a spring chicken, Pride and Sense of Well-being, Comfort and Safety, and Belonging. Interventions in this population should address negative attitudes towards aging and promote routine physical activities that enhance well-being and companionship.

Life enhancing activities for family caregivers of people with frontotemporal dementia.

Aberrant psychological and behavioral symptoms are common in patients with dementia. These symptoms have negative consequences for family caregivers, causing stress and burden. Frontotemporal dementia (FTD) symptoms cause more pronounced stress and burden on caregivers than those associated with Alzheimer dementia. In this randomized, attention control pilot study, we delivered 5-weekly, one-on-one, positive affect intervention sessions to family caregivers of people with FTD. The program, Life Enhancing Activities for Family Caregivers: LEAF was conducted in-person or by videoconference with caregivers across the United States. Measures of affect, caregiver mood, stress, distress, and caregiver burden were assessed at baseline, end of sessions, and 1 month after completion. Twenty-four caregivers (12 intervention and 12 attention control) participated. At the end of the intervention, scores on positive affect, negative affect, burden, and stress all improved in the intervention compared with the control group. These scores continued to show improvement at the assessment done 1 month after intervention. Subjects were receptive to the skills and the delivery methods. The positive emotion skill-building intervention proved feasible especially in the internet videoconference delivery format. The intervention promoted positive affect and improved psychological outcomes for family caregivers of people with FTD.

Rest–activity and behavioral disruption in a patient with frontotemporal dementia

The neurological deterioration in dementia is associated with disturbances in circadian rhythms and rest–activity patterns. These disruptions have been documented in Alzheimers disease (AD) and dementia with Lewy bodies but little is known about rest–activity patterns in patients with frontotemporal dementia (FTD). We report longitudinal (2 year) actigraphy results for a patient who met diagnostic criteria for FTD and his family caregiver. The subject and his family caregiver wore Actiwatches continuously for 2 weeks at 1-year intervals. The findings suggest that with disease progression there is worsening in multiple areas of rest–activity measures for the patient and a negative impact on sleep quality for the family caregiver.