Nonpharmacologic management of behavioral symptoms in dementia

A Multicomponent Home-Based Intervention for Neuropsychiatric Symptoms in People With Dementia and Caregivers' Burden and Depression: A 6-Month Longitudinal Study

OBJECTIVES

Many people with dementia live in their home and require ongoing care, which is often provided by informal family caregivers. Thus, we examined the effectiveness of a multicomponent home-based intervention by evaluating its impact on a) neuropsychiatric symptoms of people with dementia and b) burden and depression of their caregivers.

METHODS

During the first 6 months of this prospective single-center study, we applied a home-based multicomponent intervention in 205 dyads of care-recipients and caregivers. In further analyzes, we included only dyads of caregivers and care-recipients with available data both at baseline and 6-month follow-up (N = 144). All assessments were conducted at home and included sociodemographic features, care-recipients' clinical data, cognitive status (Mini-Mental State Examination), activities of daily living (Instrumental Activities of Daily Living; Katz Index of Independence in Activities of Daily Living), neuropsychiatric symptoms (Neuropsychiatric Inventory), and caregivers' burden (Zarit Burden Inventory) and depression (Center for Epidemiological Studies-Depression).

RESULTS

We found significant decreases in the severity (p_FDR = 0.002) and associated distress (p_FDR = 0.001) of neuropsychiatric symptoms, as well as caregivers' burden (p_FDR = 0.004) and depressive symptoms (p_FDR = 0.001). As expected, there was significant deterioration in care-recipients' cognitive status (p_FDR = 0.005) and measures of activities of daily living (p_FDR < 0.005).

CONCLUSION

Despite the progressive course of dementia, the home-based multicomponent intervention was effective in decreasing caregivers' burden and depression and minimizing care-recipients' neuropsychiatric symptoms' severity and associated distress after 6 months. Our study highlights the establishment of home-based care units as an advantageous solution, specifically for family members seen to have a "taken-for-granted" role in dementia caring.

The National Partnership to Improve Dementia Care and Hospital Readmission Among Skilled Nursing Facility Residents

The National Partnership to Improve Dementia Care in Nursing Homes (i.e., the National Partnership) was launched in March 2012. Using national Medicare, Minimum Data Set, and Nursing Home Compare data in CY 2010-2014, we examined changes in hospital readmissions for older post-acute skilled nursing facility (SNF) residents with Alzheimer's disease or related dementias (ADRD) following the National Partnership. Using residents without ADRD as reference group to control for concurrent policy and SNF quality changes, we estimated linear probability models to examine the relationship between readmissions and the National Partnership for residents with ADRD, and also stratified the analysis by quality of SNFs. We found a decreasing trend in hospital readmissions over time. The risk of readmissions in residents with ADRD decreased additional 0.3 percentage-points (p < .01) after the launch of the National Partnership. This relationship varied across SNFs with different quality, as it was stronger in high-quality compared to low-quality SNFs.

Patterns and predictors of oral antipsychotic prescribing in adult patients with schizophrenia

Background

Objective

Methods

Results

Conclusions

Assess of Combinations of Non-Pharmacological Interventions for the Reduction of Irritability in Patients with Dementia and their Caregivers: A Cross-Over RCT

Introduction: Dementia is a very common disorder that affects people over 65 years old all over the world. Apart from the cognitive decline, Behavioral and Psychological Symptoms of Dementia (BPSD) are a crucial matter in dementia, because they affect up to 90% of the patients during the course of their illness. Irritability has been found to be a common BPSD and one of the most distressing behaviors for the caregivers. The aim of the current study was to explore the efficacy of a combination of non-pharmacological interventions to treat irritability. Methods: Sixty patients with different types and stages of dementia with irritability were participated in a cross-over RCT. Three non-pharmacological interventions were used; (a) Validation Therapy (VT)/Psycho-educational program, (b) Aromatherapy/massage and (c) Music Therapy (MT). The study assessed the three non-pharmacological interventions in order to find the most effective combination of the interventions. This study did not compare pharmacological and non-pharmacological treatments. The interventions lasted for five days. There was no drop-out rate. All patients were assessed at baseline using Mini Mental State of Examination (MMSE), Addenbrooke’s Cognitive Examination Revised (ACE-R), Geriatric Depression Scale (GDS), Functional Rating Scale for symptoms in dementia (FRSSD), and Neuropsychiatric Inventory (NPI) (sub questions for irritability). Only NPI used for the assessment after each intervention. The analyses used categorical variables, Wilcoxon signed-rank test, Chi-square test and z value score. Results: The most effective combination of non-pharmacological interventions was Aromatherapy/massage (p = 0.003)-VT plus Psycho-educational program (p = 0.014) plus MT (p = 0.018). The same combination was the most effective for the caregivers’ burden, too (p = 0.026). Conclusions: The above combination of non-pharmacological interventions can reduce irritability in patients with dementia and caregivers’ burden.

The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

OBJECTIVE

To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs.

METHODS

The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated.

RESULTS

The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors.

CONCLUSION

Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

Simulation learning to train healthcare students in person-centered dementia care

In coming decades, healthcare providers will treat a greater number of individuals living with Alzheimer's Disease and related dementias than ever. Simulation-based learning provides experiential learning opportunities to enhance clinical training, but little is known about how dementia simulation training improves understanding of dementia or how it changes in participants' ability to deliver high-quality healthcare to individuals living with dementia. In this study, we examine how a simulation training program may prepare healthcare trainees to treat individuals living with dementia. We conducted eight in-depth, one-on-one interviews with healthcare trainees who participated in the Virtual Dementia Tour (VDT) program and faculty who added VDT to their curricula, and also examined 20 reflection papers from students following participation in VDT. A thematic analysis of qualitative data led us to three themes: 1) dementia simulation complements and enhances traditional teaching methods, 2) dementia simulation helps students to understand the experiences of people living with dementia, and 3) experiential learning inspired students to reflect on actions they would take as clinicians and leaders to support individuals living with dementia and their families. Based on these findings, we propose a modified transformative learning process for dementia simulation training with healthcare students.

Psychosis in Alzheimer disease - mechanisms, genetics and therapeutic opportunities

Psychosis is a common and distressing symptom in people with Alzheimer disease, and few safe and effective treatments are available. However, new approaches to symptom assessment and treatment are beginning to drive the field forward. New nosological perspectives have been provided by incorporating the emergence of psychotic symptoms in older adults - even in advance of dementia - into epidemiological and neurobiological frameworks as well as into diagnostic and research criteria such as the International Psychogeriatric Association criteria for psychosis in neurocognitive disorders, the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART) research criteria for psychosis in neurodegenerative disease, and the ISTAART criteria for mild behavioural impairment. Here, we highlight the latest findings in genomics, neuroimaging and neurobiology that are informing approaches to drug discovery and repurposing. Current pharmacological and non-pharmacological treatment options are discussed, with a focus on safety and precision medicine. We also explore trial data for pimavanserin, a novel agent that shows promise for the treatment of psychosis in people with dementia, and discuss existing agents that might be useful but need further exploration such as escitalopram, lithium, cholinesterase inhibitors and vitamin D. Although the assessment and management of psychosis in people with dementia remain challenging, new opportunities are providing direction and hope to the field.

Comparison of behaviors characteristic of autism spectrum disorder behaviors and behavioral and psychiatric symptoms of dementia

BACKGROUND

Similarities exist in behavioral expression of autism spectrum disorder (ASD) and Alzheimer's disease and related dementias (ADRD). The purpose of this study was to assess presence of behavioral and psychiatric symptoms of dementia (BPSD) and ASD-like behaviors in adults with ADRD.

METHODS

Using a cross-sectional design, data from University of Kentucky Alzheimer's Disease Center participant cohort were used. Hierarchical linear regression was used to assess (1) the relationship between ASD-like behaviors (measured by the Gilliam Autism Rating Scale-Second Edition, GARS-2) and BPSD measured by the Neuropsychiatric Inventory (NPI), and (2) the relationship between ASD-like behaviors and dementia severity (measured by the Clinical Dementia Rating [CDR] sum of boxes), when controlling for BPSD.

RESULTS

Complete data were available for 142 participants. Using α of 0.05, analyses identified ASD behaviors were significantly associated with BPSD severity ratings (r = 0.47; p < 0.001) and dementia severity (r = 0.46; p < 0.001). GARS-2 explained 6.1% (p < 0.001) of variance in CDR sum of boxes when controlling for NPI and other covariates.

DISCUSSION

There is significant overlap in behaviors characteristic of ASD and BPSD as assessed by the NPI and GARS-2, despite the use of these instruments in disparate developmental vs. aging settings. ASD behaviors appear to not be solely present in early childhood as a manifestation of ASD but are also present in older adults with neurodegenerative cognitive impairment. Such associations warrant additional research into causation, assessment, and behavioral interventions to further enable new therapeutic approaches targeting ASD behaviors across the lifespan.

The Rationale and Design of Behavioral Interventions for Management of Agitation in Dementia in a Multi-Site Clinical Trial

BACKGROUND

Agitation and aggression are common in patients with Alzheimer's disease and related dementias and pose a significant burden on patients, caregivers, and the healthcare systems. Guidelines recommend personalized behavioral interventions as the first-line treatment; however, these interventions are often underutilized. The Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study (ClinicalTrials.gov Identifier # NCT0367220) is a multisite randomized controlled trial comparing an Integrated Care Pathway, that includes a sequential pharmacological algorithm and structured behavioral interventions, with treatment-as-usual to treat agitation in dementia in long-term care and inpatient settings.

OBJECTIVE

To describe the rationale and design of structured behavioral interventions in the StaN study.

METHODS

Structured behavioral interventions are designed and implemented based on the following considerations: 1) personalization, 2) evidence base, 3) dose and duration, 4) measurement-based care, and 5) environmental factors and feasibility.

RESULTS

The process to design behavioral interventions for each individual starts with a comprehensive assessment, followed by personalized, evidence-based interventions delivered in a standardized manner with ongoing monitoring of global clinical status. Measurement-based care is used to tailor the interventions and to integrate them with pharmacotherapy.

CONCLUSION

Individualized behavioral interventions in patients with dementia may be challenging to design and implement. Here we describe a process to design and implement individualized and structured behavioral interventions in the context of a multisite trial in long-term care and inpatient settings. This process can inform the design of behavioral interventions in future trials and in clinical settings for the treatment of agitation in dementia.

Research Hotspots and Trends in Music Therapy Intervention for Patients With Dementia: A Bibliometrics and Visual Analysis of Papers Published From 2010 to 2021

BACKGROUND

As a serious public health problem, dementia has placed a heavy burden on society and families. Evidence suggests that the use of music therapy as a non-pharmacological intervention has certain advantages with respect to reducing the behavioral and psychological symptoms of dementia (BPSD) and improving the cognition and mental status of dementia patients. However, research trends and hotspots regarding music therapy intervention for dementia analysis have not been systematically studied via bibliometric analysis.

METHODS

We searched the Web of Science Core Collection (WoSCC) for texts published between January 1, 2010, and October 31, 2021, and visualized country, institution, journal, keyword co-occurrence, keyword emergence and keyword clustering.

RESULTS

A total of 217 articles from the WoSCC database were analyzed. In this research field, the annual number of publications has generally shown a slowly increasing trend, and the United States has the most publications and the most frequent cooperation among countries. University College London (UCL) has the most extensive influence among research institutions. Among articles, those published in the JOURNAL OF ALZHEIMER'S DISEASE were the most numerous, with 20 such articles being published, accounting for 9.22% (20/217) of the total. Comprehensive analysis of five clusters via biclustering shows that the research hotspots in this field during the past 11 years have mainly focused on the autobiographical memory, cognitive function, mental state and BPSD of dementia patients.

CONCLUSION

This study conducted a bibliometric and visual analysis of relevant studies concerning music therapy intervention for dementia patients. Psychological problems faced by dementia patients and the topics of quality of life, individualized music therapy, the mental state of caregivers and other related topics may be important research directions in the future. Therefore, the question of how to develop standardized research protocols and identify unified efficacy evaluation indicators should be a focus of and difficulty for future research.

Cultural Adaptation of the Reducing Disability in Alzheimer's Disease (RDAD) Protocol for an Intervention to Reduce Behavioral and Psychological Symptoms of Dementia in Thailand

BACKGROUND

The Reducing Disability in Alzheimer's Disease (RDAD) program is an evidence-based intervention found to be feasible for implementation in community settings in the United States, and effective in reducing depression, one of the major behavioral and psychological symptoms of dementia (BPSD).

OBJECTIVE

The goal of the study is to culturally adapt the RDAD for persons with dementia living in community settings of Thailand.

METHODS

Key adaptation steps included: 1) assess the community, 2) understand/select the intervention, 3) consult with experts/stakeholders, 4) decide what needs to be adapted, 5) adapt the original program, 6) train staff, and 7) pilot test the adapted materials.

RESULTS

Modifications to the original RDAD protocol included changes in number of sessions, mode of delivery, and the specific pleasant activities targeted. The pilot test demonstrated the feasibility and acceptance of the adapted RDAD intervention protocol. Implementers were able to comprehend and implement the core components of the intervention, while family members demonstrated ability to follow instructions, gain knowledge about dementia, and improve skills for setting up realistic goals.

CONCLUSION

Following the key adaptation steps outlined above, we were able to successfully modify the RDAD for the Thai cultural context, maintaining core components of the original protocol. Program implementers demonstrated their ability to supervise family caregivers and help them gain the knowledge and skills needed to provide care for older adults with dementia. Findings from the pilot studies were incorporated into final training and intervention protocols currently being implemented and evaluated in a randomized implementation trial in Thailand.

Couple and family interventions for high mortality health conditions: A strategic review (2010-2019)

The earliest publications in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. This strategic review captures an evaluation of efficacy for 87 couple and family interventions published between 2010 and 2019 with a focus on the leading causes of mortality in the United States. These health conditions include chromosomal anomalies and accidents with infants aged 0-4 years; accidents and cancer among children aged 5-14; accidents among adolescents aged 15-24; and heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer's disease, diabetes, influenza/pneumonia, and nephritis/nephrosis among adults 25 and older. Results support the need for greater inclusion of couples and families in assessments and interventions. The greatest chasm in efficacy research was with minoritized couples and families. Implications include ways to initiate couple and family interventions in the context of health conditions with attention given to accessibility, recruitment, retention, and evaluation.

Sensory Processing Abnormalities in Community-Dwelling Older Adults with Cognitive Impairment: A Mixed Methods Study

Mild cognitive impairment (MCI) or dementia often leads to behavioral and psychiatric symptoms of dementia (BPSD). Sensory processing abnormalities may be associated with BPSD. The purpose of this study was to explore relationships among sensory processing, behavior, and environmental features within the homes of people with MCI or dementia. This project used mixed methods to assess participants' sensory processing, care partner perspectives on behaviors, and in situ observations of the home environment. Nine participants with cognitive impairment (MCI n = 8, early dementia = 1) and their care partners were included. Seven participants with cognitive impairment were reported to have abnormal sensory processing. Findings suggest that unique environmental adaptations, tailored to personal and sensory preferences for each participant, were associated with a decreased level of behavioral disruption during the observation periods. Implementing sensory-based approaches to maximize environment adaptation may be beneficial in reducing disruptive behaviors for adults with cognitive impairment.

Acceptability and Preliminary Effectiveness of a Remote Dementia Educational Training Among Primary Care Providers and Health Navigators

BACKGROUND

Optimal care can improve lives of families with dementia but remains under-implemented. Most healthcare professional training is in person, time-intensive, and does not focus on key aspects such as early detection, and cultural competency.

OBJECTIVE

We explored the acceptability and preliminary effectiveness of a training, The Dementia Update Course, which addressed these issues. We hypothesized that the training would lead to increased levels of perceived dementia care competency among key healthcare workers, namely primary care providers (PCPs) and health navigators (HNs).

METHODS

We conducted pre-post training assessments among 22 PCPs and 32 HNs. The 6.5-h training was remote, and included didactic lectures, case discussion techniques, and materials on dementia detection and care. Outcomes included two 5-point Likert scales on acceptability, eleven on perceived dementia care competency, and the three subscales of the General Practitioners Confidence and Attitude Scale for Dementia. We used paired samples t-tests to assess the mean differences in all preliminary effectiveness outcomes.

RESULTS

The training included 28.6% of PCPs and 15.6% of HNs that self-identified as non-White or Latino and 45.5% of PCPs and 21.9% of HNs who served in rural areas. PCPs (84.2%) and HNs (91.7%) reported a high likelihood to recommend the training and high satisfaction. Most preliminary effectiveness outcomes analyzed among PCPs (11/14) and all among HNs (8/8) experienced an improvement from pre- to post-training (p < 0.05).

CONCLUSION

A relatively brief, remote, and inclusive dementia training was associated with high levels of acceptability and improvements in perceived dementia care competency among PCPs and HNs.

Tailored Activity Program (TAP-BR): Proposition of an outpatient care version and evaluation of its impacts on dementia - A pilot study

Abstract Introduction The Tailored Activity Program (TAP-BR) is an occupational therapy intervention program that presents promising results in reducing the behavioral and psychological symptoms of dementia (BPSD). Objectives To propose adaptations to the TAP-BR to create an outpatient care version of this program and assess its impact and applicability. Methods The TAP-BR was adapted for use and application in an outpatient care setting, and the applicability of this version was assessed according to the perception of occupational therapy interns and family caregivers. The Neuropsychiatric Inventory (NPI) and the Depression, Anxiety and Stress Scale (DASS 21) were used as outcome measures to evaluate the impact of the adapted version. Results The following changes in the application process of the TAP-BR were proposed for its outpatient format: adaptation of terms in the Intervention Manual and in the Documentation Folder; adequacy of the environmental assessment to be carried out based on an interview with the caregiver; reduction in session duration from 90 to 60 min. From the point of view of the interns and family caregivers, the program can be easily applied. The outcome measures showed that there was improvement in caregiver distress in relation to the BPSD of the older persons with dementia (Cohen’s d=0.49) and in their emotional state (Cohen’s d=0.59), especially regarding the variable depression (Cohen’s d=0.81). Conclusion: The outpatient version of TAP-BR can be easily applied, has a positive impact on reducing the BPSD in older people, and improves the emotional state of caregivers, with emphasis on the variable depression.

Programa Personalizado de Atividades (TAP-BR): proposição de uma versão ambulatorial e avaliação dos seus impactos na demência - Estudo piloto

Resumo Introdução O Programa Personalizado de Atividades (TAP-BR) é um programa de intervenção em terapia ocupacional que apresenta resultados promissores na redução dos sintomas comportamentais e psicológicos da demência (SCPD). Objetivos Propor adaptações no TAP-BR para a criação de uma versão ambulatorial desse programa e avaliar o impacto e a sua aplicabilidade. Métodos O TAP-BR foi adaptado para uso e aplicação em ambulatório e foi feita a avaliação da aplicabilidade dessa versão a partir da percepção dos estagiários do último ano do curso de graduação em terapia ocupacional e dos cuidadores familiares. O Inventário Neuropsiquiátrico (INP) e a Escala de Depressão, Ansiedade e Estresse (DASS 21) foram utilizados para avaliar o impacto da versão adaptada. Resultados Foram propostas as seguintes alterações no processo de aplicação do TAP-BR em ambulatório: adequações de termos no Manual de Intervenção e na Pasta de Documentação; adequação da avaliação ambiental a ser realizada a partir de entrevista com o cuidador; redução na duração das sessões, de 90 para 60 minutos. Na visão dos estagiários e cuidadores familiares, o programa se apresentou de fácil aplicação. As medidas apontaram que houve melhora no desgaste dos cuidadores em relação aos SCPD dos idosos (Cohen d=0,49) e em seu estado emocional (Cohen d=0,59), principalmente para a variável depressão (Cohen d=0,81). Conclusão A versão ambulatorial do TAP-BR é um programa de fácil aplicação, com impacto positivo na redução dos SCPD nos idosos e melhora no estado emocional dos cuidadores, com ênfase na variável depressão.

Family Caregivers of People with Dementia Have Poor Sleep Quality: A Nationwide Population-Based Study

Previous studies have documented cognitive impairments, psychological stress, and depressive symptoms in family caregivers of people with dementia (PWD), which could be attributed to their sleep disturbances. Notwithstanding the increasing recognition of poor sleep quality and sleep disturbances in family caregivers of PWD, their association has not been tested yet using population-representative samples. We conducted a retrospective, cross-sectional study using population-based data from the 2018 Korean Community Health Survey. Sociodemographic, mental health-related, and physical health-related variables as well as sleep quality evaluated by the Pittsburgh Sleep Quality Index (PSQI) were compared between 2537 cohabitating caregivers of PWD, 8864 noncohabitating caregivers of PWD, and 190,278 non-caregivers. Two sets of multivariable logistic regressions were conducted to examine the associations between dementia caregiving and poor sleep quality in cohabitating and noncohabitating caregivers versus noncaregivers. Both cohabitating and noncohabitating caregivers had higher global PSQI scores and higher prevalence of poor sleep quality (PSQI score > 5) than did noncaregivers. Multivariable logistic regressions adjusted for potential confounders revealed that cohabitating caregivers (odds ratio (OR) 1.26, 95% confidence interval (CI) 1.15-1.38) and noncohabitating caregivers (OR 1.15, CI 1.10-1.21) were significantly associated with poor sleep quality. Our results showed that both cohabitating and noncohabitating caregivers of PWD experienced overall poorer sleep quality compared to noncaregivers, indicating the deleterious effect of dementia caregiving on sleep quality, regardless of living arrangements. Given the high prevalence of poor sleep quality in family caregivers of PWD and the increasing awareness of the serious health consequences of poor-quality sleep, physicians should consider active sleep interventions to promote health and wellbeing not only for the dementia patients but also for family caregivers.

Degree of personalisation in tailored activities and its effect on behavioural and psychological symptoms and quality of life among people with dementia: a systematic review and meta-analysis

OBJECTIVES

To understand and assess the degree of personalisation of tailored activities for people with dementia (PWD); and to estimate the magnitude of the effects of levels of personalisation on reducing behavioural and psychological symptoms of dementia (BPSD), improving quality of life (QoL) and level of engagement.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

ProQuest, PubMed, Ovid, Cochrane Library, Web of Science and CINAHL were searched from the start of indexing to May 2020.

ELIGIBILITY CRITERIA

We included randomised controlled trials and quasi-experimental studies assessing the effects of tailored activities for people aged 60 years or older with dementia or cognitive impairment on the outcomes of BPSD, QoL, depression and level of engagement with control groups.

DATA EXTRACTION AND SYNTHESIS

Two researchers screened studies, extracted data and assessed risks of bias. A rating scheme to assess the degree of personalisation of tailored activities was developed to classify tailored activities into high/medium/low groups. Effect sizes were expressed using standardised mean differences at 95% Confidence Interval (CI). Subgroup analyses were conducted to assess whether the degree of personalisation of tailored activities affected outcomes of interest.

RESULTS

Thirty-five studies covering 2390 participants from 16 countries/regions were identified. Studies with a high-level of personalisation interventions (n=8) had a significant and moderate effect on reducing BPSD (standardised mean differences, SMD=-0.52, p<0.05), followed by medium (n=6; SMD=-0.38, p=0.071) and low-level personalisation interventions (n=6; SMD=-0.15, p=0.076). Tailored activities with a high-level of personalisation had a moderate effect size on improving QoL (n=5; SMD=0.52, p<0.05), followed by a medium level (n=3; SMD=0.41, p<0.05) of personalisation.

CONCLUSIONS

To develop high-level tailored activities to reduce BPSD and improve QoL among PWD, we recommend applying comprehensive assessments to identify and address two or more PWD characteristics in designed tailored activities and allow modification of interventions to respond to changing PWD needs/circumstances.

PROSPERO REGISTRATION NUMBER

CRD42020168556.

Factors Associated With Behavioral and Psychological Symptoms of Dementia: Prospective Observational Study Using Actigraphy

BACKGROUND

Although disclosing the predictors of different behavioral and psychological symptoms of dementia (BPSD) is the first step in developing person-centered interventions, current understanding is limited, as it considers BPSD as a homogenous construct. This fails to account for their heterogeneity and hinders development of interventions that address the underlying causes of the target BPSD subsyndromes. Moreover, understanding the influence of proximal factors-circadian rhythm-related factors (ie, sleep and activity levels) and physical and psychosocial unmet needs states-on BPSD subsyndromes is limited, due to the challenges of obtaining objective and/or continuous time-varying measures.

OBJECTIVE

The aim of this study was to explore factors associated with BPSD subsyndromes among community-dwelling older adults with dementia, considering sets of background and proximal factors (ie, actigraphy-measured sleep and physical activity levels and diary-based caregiver-perceived symptom triggers), guided by the need-driven dementia-compromised behavior model.

METHODS

A prospective observational study design was employed. Study participants included 145 older adults with dementia living at home. The mean age at baseline was 81.2 (SD 6.01) years and the sample consisted of 86 (59.3%) women. BPSD were measured with a BPSD diary kept by caregivers and were categorized into seven subsyndromes. Independent variables consisted of background characteristics and proximal factors (ie, sleep and physical activity levels measured using actigraphy and caregiver-reported contributing factors assessed using a BPSD diary). Generalized linear mixed models (GLMMs) were used to examine the factors that predicted the occurrence of BPSD subsyndromes. We compared the models based on the Akaike information criterion, the Bayesian information criterion, and likelihood ratio testing.

RESULTS

Compared to the GLMMs with only background factors, the addition of actigraphy and diary-based data improved model fit for every BPSD subsyndrome. The number of hours of nighttime sleep was a predictor of the next day's sleep and nighttime behaviors (odds ratio [OR] 0.9, 95% CI 0.8-1.0; P=.005), and the amount of energy expenditure was a predictor for euphoria or elation (OR 0.02, 95% CI 0.0-0.5; P=.02). All subsyndromes, except for euphoria or elation, were significantly associated with hunger or thirst and urination or bowel movements, and all BPSD subsyndromes showed an association with environmental change. Age, marital status, premorbid personality, and taking sedatives were predictors of specific BPSD subsyndromes.

CONCLUSIONS

BPSD are clinically heterogeneous, and their occurrence can be predicted by different contributing factors. Our results for various BPSD suggest a critical window for timely intervention and care planning. Findings from this study will help devise symptom-targeted and individualized interventions to prevent and manage BPSD and facilitate personalized dementia care.

Effects of the tailored activity program (TAP) on dementia-related symptoms, health events and caregiver wellbeing: a randomized controlled trial

Background

People living with dementia (PLWD) and caregivers are adversely impacted by lack of meaningful activity leading to worse symptoms and impaired quality-of-life. There is a critical need to develop effective and well-tolerated treatments that mitigate clinical symptoms, engage PLWD and support caregiver wellbeing. We tested whether, compared to attention control, the Tailored Activity Program (TAP) reduced clinical symptoms and health-related events, and improved caregiver wellbeing, and if TAP activities were well-tolerated.

Methods

We conducted a single-blind randomized controlled trial among 250 dyads recruited from Baltimore-Washington DC (2012–2016) with a dementia diagnosis and clinically significant agitation/aggression. Dyads were randomized to TAP (n = 124) or attention control (n = 126), and interviewed at baseline, 3 (endpoint) and 6-months (follow-up) by interviewers masked to group allocation. TAP assessed PLWD abilities/interests, instructed caregivers in using prescribed activities, and provided dementia education and stress reduction techniques. Attention controls received disease education and home safety tips. Both groups had up to 8 home visits over 3-months. The primary outcome was frequency by severity scores for agitation/aggression subscales of Neuropsychiatric Inventory-Clinician using caregiver ratings. Secondary outcomes included number of instrumental (IADL) and activities of daily living (ADL) needing assistance, caregiver wellbeing, and confidence using activities. Health-related events (PLWD death, hospitalizations, caregiver hospitalization, depression) and perceived study benefits were captured over 6 months. PLWD tolerability of prescribed activities was examined.

Results

Of 250 dyads, most caregivers were female (81.2 %, n = 203), non-spouses (54.4 %, n = 136), white (59.2 %, n = 145) or African American (36.7 %, n = 90) with mean age = 65.4 (SD = 12.6). PLWD were mostly female (63.2 %, n = 158) with mean age = 81.4 (SD = 7.9), and mean MMSE = 14.3 (SD = 7.8). At 3-months, compared to controls, TAP conferred no benefit to agitation/aggression (p = 0.43, d = 0.11), but resulted in less IADL (p = 0.02, d=-0.33), and ADL (p = 0.04, d=-0.30) assistance, improved caregiver wellbeing (p = 0.01, d = 0.39), and confidence using activities (p = 0.02, d = 0.32). By 6-months, 15 PLWD in TAP had ≥ 1 health-related event versus 28 PLWD in control, demonstrating 48.8 % improvement in TAP (p = 0.03). TAP caregivers were more likely to perceive study benefits. Prescribed activities were well-tolerated.

Conclusions

Although TAP did not benefit agitation/aggression, it impacted important outcomes that matter to families warranting its use in dementia care.

Clinical trial registration

Clinicaltrials.gov # NCT01892579 at https://clinicaltrials.gov/; Date of clinical trial registration: 04/07/2013; Date first dyad enrolled: 15/11/2013.

Effectiveness of "Reducing Disability in Alzheimer's Disease" Among Dyads With Moderate Dementia

Replications of evidence-based dementia care receiver-caregiver dyad interventions in the community are scarce. We aimed to assess the effectiveness of the Kansas City implementation of Reducing Disability in Alzheimer's Disease (RDAD) among a convenience sample of dyads with moderate dementia, which addressed needs identified by nine participating community agencies. We hypothesized that dyads' mental health and physical activity outcomes would improve from baseline to end-of-treatment. The final analytic sample included 66 dyads. Outcomes improved (p < .01) from pre- to post-intervention: behavioral symptom severity (range 0-36) decreased from 11.3 to 8.6, physical activity increased from 125.0 to 190.0 min/week, caregiver unmet needs (range 0-34) decreased from 10.6 to 5.6, caregiver behavioral symptom distress (0-60) decreased from 15.5 to 10.4, and caregiver strain (0-26) decreased from 11.1 to 9.7. This adapted implementation of RDAD leads to clinically meaningful improvements and might inform scaling-up.

Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions

Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.

Risks as dilemmas for home care staff caring for persons with dementia

OBJECTIVES

Many persons with dementia live at home with support from home care services. Despite this, research is scarce concerning how risks in daily life among persons with dementia are perceived and handled by home care staff. This study aimed to explore how home care staff identify risks in the everyday lives of persons with dementia, and to inquire into how they reasoned about their own actions related to those risks.

METHOD

A qualitative approach was applied for the study. Both individual interviews and focus groups were conducted with home care staff (n = 23). Data was analysed using a constant comparative method.

RESULTS

Identifying, reasoning and acting upon risks in the everyday lives of persons with dementia were related to several dilemmas for the home care staff. These dilemmas are described and elaborated on in three categories: 1) Strategies for tracking risks, 2) Dilemmas concerning where to draw the line and deciding when to act, and 3) Dilemmas when acting on risks.

CONCLUSION

The study provides new knowledge about the dilemmas that staff in home care services may face and how they reason about managing risks in the homes of persons with dementia. The study shows that the staff had to weigh risk and safety against the autonomy of persons with dementia. Based on these findings, we want to highlight the importance of competence among home care staff and the organizational conditions that must exist in order to manage the challenges of risky situations.

Efficacy of serotonergic antidepressant treatment for the neuropsychiatric symptoms and agitation in dementia: A systematic review and meta-analysis

OBJECTIVE

Serotonergic dysfunction may be involved in the etiology of overall neuropsychiatric symptoms (NPS) and agitation in patients with dementia; therefore, we aim to perform a systematic review and meta-analysis to investigate the efficacy of serotonergic antidepressants in such populations.

METHODS

We systematically searched PubMed, Medline, Embase, and Cochrane Library to obtain randomized controlled trials (RCTs) from the date of their inception until December 11, 2020 to examine the effect of serotonergic antidepressants on the outcomes of interest in patients with dementia. Data were pooled using a random-effects model. Co-primary outcomes were mean changes in overall NPS and agitation as a specific symptom of NPS. Secondary outcomes were mean changes in depressive symptoms, cognition, and care burden.

RESULTS

Fourteen randomized controlled trials were eligible (n = 1,374; mean age = 76.8 years; mean proportion of female = 61.9 %). Serotonergic antidepressants significantly reduced the overall NPS (k = 12, n = 1276, Hedges' g = -0.49, 95 % confidence intervals [CIs] = -0.74 to -0.24, p < 0.001) and agitation severity (k = 9, n = 749, Hedges' g = -0.28, 95 % CIs = -0.43 to -0.14, p < 0.001), both with small effect size in patients with dementia. For secondary outcome, serotonergic antidepressants also significantly improved depressive symptoms, cognition, and care burden with small to very small effect sizes (depressive symptoms, k = 8, n = 938, Hedges' g = -0.32, 95 % CIs = -0.49 to -0.15, p < 0.001;cognition, k = 6, n = 983, Hedges' g = 0.15, 95 % CIs = 0.002 to 0.29, p = 0.046; care burden, k = 7, n = 961, Hedges' g = -0.24, 95 % CIs = -0.41 to -0.07, p = 0.005). Subgroup analysis showed that both selective serotonin reuptake inhibitors (SSRIs) and non-SSRIs significant reduced agitation and depressive symptoms (For agitation, SSRIs, k = 6, n = 605, Hedges' g = -0.25, 95 % CIs = -0.41 to -0.09, p=0.002; non-SSRIs, k = 3, n = 144, Hedges' g = -0.41, 95 % CIs = -0.74 to -0.08, p = 0.016; For depression, SSRIs, k = 6, n = 736, Hedges' g = -0.29, 95 % CIs = -0.48 to -0.09, p=0.004; non-SSRIs, k = 343, n = 144, Hedges' g = -0.43, 95 % CIs = -0.78 to -0.09, p = 0.016), whereas only SSRIs reduced overall NPS (k = 9, n = 1109, Hedges' g = -0.49, 95 % CIs = -0.78 to -0.20, p = 0.001) and care burden (k = 5, n = 740, Hedges' g = -0.29, 95 % CIs = -0.50 to -0.08, p=0.007).

CONCLUSION

The present meta-analysis indicates that serotonergic antidepressants effectively alleviate overall NPS, agitation, depressive symptoms, and care burden, and improve cognitive function.

COVID-19 Lockdown Effect on Not Institutionalized Patients with Dementia and Caregivers

SARS-COV-2 is a severe medical condition. Old patients are very vulnerable, but they have been studied only as institutionalized patients. During the lock-down, little attention is dedicated to old, demented patients who lived at home. This study wants to examine their behavioral reactions by video-phone follow-up. We conducted a longitudinal study in subcortical vascular dementia (sVAD) patients. We enrolled 221 sVAD, not institutionalized patients. We divided sVAD patients into low-medium grade sVAD (A) and severe sVAD (B), based on neuroimaging severity degree and executive alterations. At baseline, at the end of lock-down, and two months later, global behavioral symptoms were recorded for each patient. We found significantly higher scores of general behavioral deterioration, anxiety, delusions, hallucinations and apathy after controlling for sVAD severity. The direct consequence was a drastic increment of psychotropic drugs prescribed and employed during the lock-down. Moreover, caregivers' stress has been evaluated, together with their anxiety and depression levels. During the lock-down, their scores increased and reflected a severe worsening of their behavior. Our data demonstrate that social isolation induces a severe perception of loneliness and abandonment; these fears can exacerbate behavior disturbances in old-aged frail persons. Thus, these can be considered as indirect victims of SARS-COV-2.

Self-Reported Behavioral Symptoms of People with Dementia: A Pilot Study Examining Individual's Perceived Illness Experience

BACKGROUND AND OBJECTIVES

Persons with dementia experience behavioral symptoms, such as agitation and repeating questions, which have been reported as one of the most burdensome and stressful aspects of providing care for dementia caregivers. However, no published studies have assessed the subjective experience of behavioral symptoms and distress from people with dementia.

RESEARCH DESIGN AND METHODS

The current pilot study examined the feasibility of people with dementia providing self-reported behaviors and behavioral-related distress. Data from a larger, on-going research study was used consisting of people with mild to moderate dementia (n = 12) residing in a long-term memory care facility.

RESULTS

Participants were able to provide reliable (∝=.91) self-reported data concerning their own behaviors and behavioral-related distress with variability among responses. The most frequently self-reported behaviors included agitation (66.7%) and complaining/criticizing things (58.3%) while the least reported behaviors were refusing to be left alone (8.3%) and yelling/swearing (8.3%). The highest behavioral distress reported was agitation (58.3%) while the least was wandering (8.3%).

DISCUSSION AND IMPLICATIONS

Understanding the subjective, perceived experience of people with dementia provides valuable information on the illness experience. Additional research is needed to examine the role and impact of self-reported behaviors and the resulting behavioral- related distress on outcomes of well-being. Subjective reports of behavioral-related distress could predict well-being, above and beyond that of traditional objective measures, creating the potential for novel non-pharmacological intervention development for people with dementia.

Potentially Inappropriate Medication Use in Older Adults with Alzheimer's Disease and Related Dementias Living in the Community: A Cross-Sectional Analysis

BACKGROUND

With the older adult population in the USA increasing, so is the population of those with Alzheimer's disease and related dementias (ADRD). Older adults are vulnerable to the effects of potentially inappropriate medications as established by the Beers Criteria; however, some medications continue to be prescribed against recommendations.

OBJECTIVES

Our objectives were to describe potentially inappropriate medication (PIM) use linked to cognitive impairment or decline (referred to as Cog-PIM) in older adults with and without ADRD and to investigate whether the odds of Cog-PIM report differ by ADRD status in ambulatory care (i.e., outpatient care) in the USA.

METHODS

A cross-sectional analysis was performed using a nationally representative sample of non-perioperative, office-based ambulatory care visits by adults aged ≥ 65 years in 2016 (n = 218,182,131). Data were collected from the National Ambulatory Medical Care Survey. Cog-PIMs were identified as defined in the 2015 Beers Criteria recommendations for medications that may be potentially inappropriate in older adults with cognitive impairment or dementia. ADRD status was determined by clinician report using free text, the ADRD flag, or the presence of a diagnosis code indicating dementia. Multivariable logistic regressions were used to estimate the odds of Cog-PIM use overall and by medication class.

RESULTS

In 2016, 2.1% (n = 4,651,563) of outpatient visits were made by older adults with ADRD, 33.2% of which reported at least one Cog-PIM. Anticholinergic Cog-PIMs were noted in 20.5% of ADRD visits compared with 8.1% of non-ADRD visits. Antipsychotic PIMs were noted in 15.5% of ADRD visits compared with 0.8% of non-ADRD visits. Benzodiazepine and non-benzodiazepine receptor agonist hypnotic (Z drug) Cog-PIMs were reported in 10.9% of ADRD visits and 10.7% of non-ADRD visits. ADRD status was a significant predictor of Cog-PIM report overall (adjusted odds ratio [aOR] 2.74 [95% confidence interval {CI} 1.20-6.27]) and for anticholinergics and antipsychotics specifically (aOR 3.35 [95% CI 1.24-9.03] and aOR 22.80 [95% CI 5.80-89.50], respectively).

CONCLUSION

This study demonstrated a high prevalence of Cog-PIM use and increased odds of Cog-PIM use in older adults with ADRD. Future work should investigate opportunities in the ambulatory care setting for safer prescribing and de-escalation of Cog-PIMs.

Caregiver Response to an Online Dementia and Caregiver Wellness Education Platform

BACKGROUND

Web-based educational interventions are emerging as a potential solution to improve caregiver dementia knowledge and overall well-being.

OBJECTIVE

To assess the feasibility of delivering a web-based intervention for dementia caregivers by examining: 1) engagement with the online platform, 2) skill implementation, and 3) changes on outcome metrics over the 30-day study period.

METHODS

Enrolled participants were onboarded by a trained research coordinator and provided 24/7 access to the platform over 30 days. At study onset and completion, caregivers completed assessments of care recipient dementia severity and neuropsychiatric symptoms along with instruments which measured dementia knowledge, caregiver burden, and carer experience.

RESULTS

Of 84 referrals, 60 caregivers met study inclusion criteria and 55 completed pre and post study measures. Caregivers completed an average of 8 hours of learning over the 30-day web-based intervention, with 84.4%of participants reporting using at least one skill they learned from the online platform. Eighty-nine percent of participants reported high satisfaction with the web-based educational intervention. There were small effect sizes for decreases in NPIQ neuropsychiatric symptom severity and caregiver distress scores from pre- to post-intervention. Small effect sizes were observed for changes in caregiver burden from pre- to post-intervention among caregivers who perceived their care recipient as having high global deterioration.

CONCLUSION

Findings show online educational programs are feasible for informal family caregivers of dementia and have perceived value. Future studies should address caregiver response to online education in less severe versus more severe care recipients, and explore the value of caregiver online platforms in diverse caregiver samples.

Cannabis Use in Older Adults: A Perspective

The prevalence of cannabis use among older adults (aged 65 and above) for both recreational and medicinal purposes has significantly increased in recent years. Information regarding the safety of cannabis in this population is important since aging is associated with metabolic changes, multiple morbidities, increases in prescription medication use, and an overall decline in functioning. In this Perspectives article, we review special considerations pertinent to older adults-specifically, the impact of cannabis on cognition and on falls and injuries, its drug interactions, and its potential medicinal applications for treating the behavioral and psychological symptoms of dementia. Knowledge about the role of cannabis in brain health, injury risk, and drug interactions remains limited since the available evidence stems primarily from adolescent and young adult cohorts, plus a limited number of small observational studies with older adults. In terms of utilizing certain cannabinoids to treat the behavioral and psychological symptoms of dementia, some studies have found promising results, but because of the lack of consistency in the literature, it is premature to draw conclusions. Controlled research trials specifically with geriatric participants are needed to understand the effects of cannabis use in this vulnerable population.

Rationale, Design, and Methodology of a Prospective Cohort Study for Coping with Behavioral and Psychological Symptoms of Dementia: The RECage Project

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are quite challenging problems during the dementia course. Special Care Units for people with dementia (PwD) and BPSD (SCU-B) are residential medical structures, where BPSD patients are temporarily admitted, in case of unmanageable behavioral disturbances at home.

OBJECTIVE

RECage (REspectful Caring for AGitated Elderly) aspires to assess the short and long-term effectiveness of SCU-Bs toward alleviating BPSD and improving the quality of life (QoL) of PwD and their caregivers.

METHODS

RECage is a three-year, prospective study enrolling 500 PwD. Particularly, 250 community-dwelling PwDs presenting with severe BPSD will be recruited by five clinical centers across Europe, endowed with a SCU-B, for a short period of time; a second similar group of 250 PwD will be followed by six other no-SCU-B centers solely via outpatient visits. RECage's endpoints include short and long-term SCU-B clinical efficacy, QoL of patients and caregivers, cost-effectiveness of the SCU-B, psychotropic drug consumption, caregivers' attitude toward dementia, and time to nursing home placement.

RESULTS

PwD admitted in SCU-Bs are expected to have diminished rates of BPSD and better QoL and their caregivers are also expected to have better QoL and improved attitude towards dementia, compared to those followed in no-SCU-Bs. Also, the cost of care and the psychotropic drug consumption are expected to be lower. Finally, PwD followed in no-SCU-Bs are expected to have earlier admission to nursing homes.

CONCLUSION

The cohort study results will refine the SCU-B model, issuing recommendations for implementation of SCU-Bs in the countries where they are scarce or non-existent.

A longitudinal evaluation of family caregivers' willingness to pay for an in-home nonpharmacologic intervention for people living with dementia: results from a randomized trial

OBJECTIVE

To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD).

DESIGN

Randomized clinical trial.

SETTING

Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC.

PARTICIPANTS

250 dyads.

INTERVENTION

Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use.

MEASUREMENT

At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence.

RESULTS

At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: -$5.00, $25.47) and $7.15 (95%CI: -$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was -12% (95%CI: -28%, -5%) and -7% (95%CI:-25%, -11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: -$2.57, $28.17).

CONCLUSIONS

Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

Exploring how triads of people living with dementia, carers and health care professionals function in dementia health care: A systematic qualitative review and thematic synthesis

BACKGROUND

Many qualitative studies report the post-diagnostic care experiences of carers and people living with dementia; however, this is not often accompanied by opportunities to hear the corresponding views of their health care professionals and how this triadic relationship functions. The aim of this review was to identify and thematically synthesize the experiences of health care services reported by people living with dementia, their carers and health care professionals.

METHODS

Medline, PsycINFO, Embase and CINAHL were searched from inception to 31 July 2019 for qualitative research including people living with dementia, carers and health care professionals. Data were coded and thematically synthesised using NVivo.

RESULTS

Of 10,045 search results, 29 papers relating to 27 studies were included in the final synthesis, including 261 people living with dementia, 444 carers and 530 health care professionals. Six themes emerged related to the functioning of a dementia care triad: (1) involving the person living with dementia, (2) establishing expectations of care and the roles of the members of the triad, (3) building trust, (4) effective communication, (5) continuity of care and (6) understanding the unique relationship dynamics within each triad.

DISCUSSION

The interactions and complexity of triadic dementia care relationships further our understanding of how to improve dementia care. Awareness of possible diverging attitudes highlights areas of necessary improvement and further research into facilitating engagement, such as when multiple professionals are involved or where there are mismatched expectations of the roles of triad members. In order to operate efficiently as a triad member, professionals should be aware of how pre-existing relations can influence the composition of a triad, encourage the involvement of the person living with dementia, clarify the expectations of all parties, establish trusting relationships and enable communication within the direct triad and beyond.

Feasibility and preliminary effectiveness of an online training and support program for caregivers of people with dementia in India: a randomized controlled trial

OBJECTIVES

Internet-based interventions involving elements of cognitive behavior therapy, psychoeducation, relaxation and skills training for caregivers of people with dementia have been found to be promising in Western countries. Given these outcomes, the adapted version of a multi-component online caregiver skills training and support program of the World Health Organization, called iSupport, was tested for feasibility and preliminary effectiveness in India.

METHODS

One hundred fifty-one caregivers of family members with a diagnosis of Alzheimer's disease or dementia were randomized to either the intervention arm (iSupport; n = 74) or to the control group (an education-only e-book program; n = 77). Participants were assessed using self-rated measures of depression and perceived burden, which were the primary outcome measures, at baseline and 3-month follow-up. Person-centered attitude, self-efficacy, mastery and self-rated health were also assessed.

RESULTS

Fifty-five caregivers (29 in the iSupport group and 26 in the control condition) completed the study. The recruitment and retention rate of the study were 44.67% and 36.42% respectively. No significant differences were found between the two groups at 3-month follow-up on the primary outcomes. Among the secondary outcomes, significant improvement was only seen in caregivers' person-centered attitude towards persons with dementia in the iSupport group (t = 2.228; p < 0.05).

CONCLUSIONS

Despite efforts to recruit and retain participants to the online program, this study had a low recruitment and retention rate, which require closer attention and indicates a need for further adaptations of the Indian version of the iSupport program to improve its acceptability and accessibility. The lessons learned from this study will guide the further development of caregiver training and support interventions in India. The trial was registered with the Clinical Trials Registry-India (Trial Registration No. CTRI/2017/02/007876).

WeCareAdvisor, an Online Platform to Help Family Caregivers Manage Dementia-Related Behavioral Symptoms: an Efficacy Trial in the Time of COVID-19

Dementia-related behavioral and psychology symptoms (BPSD) are undertreated and have negative consequences. However, families do not have access to disease information, tailored problem-solving  and effective management strategies, and with COVID-19, are more socially isolated and distressed. To address this dementia care gap, we describe a Phase III efficacy trial testing an online platform, WeCareAdvisor, and design modifications necessitated by COVID-19. WeCareAdvisor provides caregivers with disease information, daily tips, and a systematic approach for describing behaviors, investigating underlying causes, creating tailored strategies, and evaluating their effectiveness (DICE). The trial will enroll 326 caregivers nationwide, randomly assign them to immediately receive WeCareAdvisor (treatment), or a 3-month waitlist (control) and evaluate short (1- and 3-month) and long-term (6-month) outcomes for caregiver distress with and confidence managing BPSD, and BPSD occurrences. We will also evaluate utilization patterns with different prompting conditions: high-intensity (telephone and email reminders), low-intensity (email reminders), or no reminders to use WeCareAdvisor. COVID-19 necessitated design modifications resulting in greater inclusivity of caregivers from diverse races, ethnicities, and geographic areas. Key modifications include shifting from in-home, in-person interviewing to telephone; adjusting tool functionality from operating on a grant-funded iPad to caregivers' personal internet-capable devices; and expanding recruitment from one metropolitan area to nationwide. Study modifications necessitated by COVID-19 facilitate national outreach, easier tool adoption, and enable more diverse caregivers to participate. This study addresses a critical dementia care need, and design modifications may shorten timeline from efficacy testing to commercialization.

Smoking and Alcohol Consumption Following a New Dementia Diagnosis

OBJECTIVES

Despite extensive research on lifestyle factors that influence the risk of developing dementia, limited evidence exists on whether older adults adopt healthier habits post-diagnosis in the hope of preserving their quality of life.

METHOD

Using panel data (1998-2014) from the Health and Retirement Study, this study investigated whether individuals who received a new dementia diagnosis were more likely to modify smoking and drinking behaviors than those without such a diagnosis. Propensity score weighting was used to adjust for observable differences between groups.

RESULTS

Older adults with a new dementia diagnosis were 2.8 times more likely to reduce alcohol consumption than those without such a diagnosis. This result was mainly attributable to "light" drinkers at baseline and appeared to fade over time. We found no statistically significant effect of a dementia diagnosis on smoking cessation or on reduction in the number of cigarettes smoked. These results were robust to multiple sensitivity tests, including the use of cognition scores to indicate dementia onset instead of self-reported physician diagnosis.

DISCUSSION

A new dementia diagnosis can serve as a window of opportunity that prompts some older adults to change habits related to alcohol consumption. This has important implications for clinical practice surrounding dementia diagnosis disclosure, the rates of which are currently much lower than other medical conditions.

Developing a virtual reality for people with dementia in nursing homes based on their psychological needs: a feasibility study

Background

The purpose of this study was (1) to develop a virtual reality (VR) intervention program based on the psychological needs of patients residing in nursing facilities in South Korea to alleviate their behavioral and psychological symptoms and (2) to confirm the possibility of utilizing VR in patients with dementia.

Methods

In the first phase, patients with dementia residing in nursing homes and experiencing behavioral and psychological symptoms were recruited. Surveys and questionnaires were used to identify activities that alleviated the behavioral and psychological symptoms of dementia (BPSD) among the patients. These activities were classified into five types of psychological needs. In the second phase, a fully immersive, interactive, easy-to-use VR platform was developed that reflected these psychological needs. Patients with dementia experienced the VR content. The researchers assessed the level of the participants’ immersion, preference, and interaction with the VR using a 5-point Likert scale.

Results

In the feasibility test, 10 nursing home residents were recruited. The mean immersion score was 4.93 ± 0.16 points, the mean preference score was 4.35 ± 0.41 points, and the mean interaction score was 3.84 ± 0.43 points using a 5-point Likert scale. Higher mean scores indicated a more positive outcome. Six of the 10 participants required assistance while using the VR. The mean VR experience duration was 10.00 ± 3.46 min.

Conclusions

The VR-based intervention program that was developed to reduce BPSD was feasible for the participants and provided them with a high degree of satisfaction and immersion. Furthermore, this study also confirmed the convenience and safety of the program. These findings support the potential use of VR-based BPSD intervention programs to treat patients with dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02125-w.

Association of Dementia-Related Psychosis With Long-term Care Use and Death

OBJECTIVE

To determine the association of dementia-related psychosis (DRP) with death and use of long-term care (LTC); we hypothesized that DRP would be associated with increased risk of death and use of LTC in patients with dementia.

METHODS

A retrospective cohort study was performed. Medicare claims from 2008 to 2016 were used to define cohorts of patients with dementia and DRP. Outcomes were LTC, defined as nursing home stays of >100 consecutive days, and death. Patients with DRP were directly matched to patients with dementia without psychosis by age, sex, race, number of comorbid conditions, and dementia index year. Association of DRP with outcomes was evaluated using a Cox proportional hazard regression model.

RESULTS

We identified 256,408 patients with dementia. Within 2 years after the dementia index date, 13.9% of patients developed DRP and 31.9% had died. Corresponding estimates at 5 years were 25.5% and 64.0%. Mean age differed little between those who developed DRP (83.8 ± 7.9 years) and those who did not (83.1 ± 8.7 years). Patients with DRP were slightly more likely to be female (71.0% vs 68.3%) and white (85.7% vs 82.0%). Within 2 years of developing DRP, 16.1% entered LTC and 52.0% died; corresponding percentages for patients without DRP were 8.4% and 30.0%, respectively. In the matched cohort, DRP was associated with greater risk of LTC (hazard ratio [HR] 2.36, 2.29-2.44) and death (HR 2.06, 2.02-2.10).

CONCLUSIONS

DRP was associated with a more than doubling in the risk of death and a nearly 2.5-fold increase in risk of the need for LTC.

Cost-effectiveness of a telehealth intervention for in-home dementia care support: Findings from the FamTechCare clinical trial

Determining the cost-effectiveness of technological interventions is a crucial aspect in assuring these interventions can be adopted. The FamTechCare intervention is an innovative telehealth support that links family caregivers of persons living with dementia to tailored feedback from dementia care experts based on caregiver-initiated video recordings of challenging care situations. The FamTechCare intervention has demonstrated significant reductions in caregiver depression and increases in caregiver competence when compared to standard telephone support. The purpose of this article is to report on the cost-effectiveness of the FamTechCare telehealth intervention. Process-based costing and a cost-effectiveness analysis using the incremental cost-effectiveness ratio (ICER) was completed with 68 caregiver and person living dementia with dyads. The cost of the 12-week FamTechCare telehealth intervention was found to be greater ($48.43 per dyad per week) due to the telehealth equipment, recording application, and expert panel time compared with the telephone support intervention ($6.96 per dyad per week). The ICER was $18.51 for caregiver depression and $36.31 for caregiver competence indicating that it cost no more than $36.38 per dyad per week over 12 weeks to achieve significant improvement in depression and competence in the FamTechCare caregivers compared to the telephone support caregivers. The FamTechCare intervention appears to be cost-effective when compared to the telephone support intervention and remains near the willingness-to-pay threshold for caregivers providing in-home dementia care support.

Attitudes, beliefs, and changing trends of cannabidiol (CBD) oil use among caregivers of individuals with Alzheimer's disease

OBJECTIVES

With the increasing popularity of CBD-based products, especially CBD oil, it is increasingly important to understand what motivates caregivers of individuals with Alzheimer's disease (AD) to use CBD oil as part of treatment. The purpose of this study was to identify the attitudes and beliefs of caregivers of individuals with AD toward CBD oil in Poland, to identify factors that might be associated with the decision to use CBD oil among caregivers, and to explore whether such a decision was discussed with a healthcare professional.

METHOD

A cross-sectional online survey was conducted in Poland. Participation in the study was entirely voluntary and completely anonymous. Caregivers (n = 73) were asked about their practices and attitudes regarding CBD oil.

RESULTS

The most common source of knowledge about CBD oil was an online support group for caregivers. The vast majority of caregivers found CBD to be effective in managing behavioral symptoms of AD and believed that healthcare professionals should offer CBD oil as a part of treatment. However, only 63 % (n = 46) reported consulting with their physician about using CBD oil. The study also demonstrated that some caregivers thought that CBD oil use was illegal in Poland and that their care-recipient may develop a dependence and withdrawal symptoms if they stopped using it.

CONCLUSIONS

The results of the study highlight the positive and negative perceptions among caregivers of people with AD. The study also emphasizes the importance of enhancing communication between caregivers and healthcare professionals to discuss the use of CBD oil in the treatment of individuals with AD.

Promoting Reminiscences with Virtual Reality Headsets: A Pilot Study with People with Dementia

This study aimed to explore the feasibility and effects of promoting reminiscences, using virtual reality (VR) headsets for viewing 360° videos with personal relevance, with people with dementia. A study with a mixed methods design was conducted with nine older adults diagnosed with dementia. Interventions consisted of four sessions, in which the participants’ engagement, psychological and behavioral symptoms, and simulation sickness symptoms were evaluated. Neuropsychiatric symptomatology and quality of life were measured pre- and post-intervention. Caregivers were interviewed regarding the effect of the approach. In most cases, participants appeared to enjoy the sessions, actively explored the 360° environment, and shared memories associated with the depicted locations, often spontaneously. There were no cases of significant increases in simulator sickness and psychological and behavioral symptoms during sessions, with only some instances of minor eyestrain, fullness of head, anxiety, irritability, and agitation being detected. Although there were no significant changes in the measured outcomes after intervention, the caregivers assessed the experience as potentially beneficial for most participants. In this study, promoting reminiscences with VR headsets was found to be a safe and engaging experience for people with dementia. However, future studies are required to better understand the added value of immersion, using VR, in reminiscence therapy.

Moving Evidence-Informed Assessment and Management of Behavioral and Psychological Symptoms of Dementia into the Real World: Training Family and Staff Caregivers in the DICE Approach

OBJECTIVE

To investigate the impact of a one-day training program on caregivers' confidence and knowledge in managing aspects of dementia care.

DESIGN

One-day caregiver training program featuring: 1) an interactive, multi-media format; 2) a companion manual; and 3) a "brain-storming" session at the end of the day that utilized attendees' real-world cases where the use of the DICE (Describe, Investigate, Create, and Evaluate) approach was illustrated "live."

SETTING

Three different geographical sites in Michigan.

PARTICIPANTS

Family (n = 40) and professional (paid; n = 140) caregivers (total n = 180) for people with dementia.

MEASURES

Pre- and post self-ratings related to confidence in aspects of dementia care management before and directly after the training.

RESULTS

Comparing self-ratings pre- and post-training, more than 50% of family caregivers showed improvement in confidence post-training on 11 of 12 items with significant improvement in 4 items. Among professionals, more than 50% of caregivers showed improved confidence on 3 of 12 items, with 4 items showing significant improvement. Family caregivers were significantly more likely than professionals to show improved confidence on 6 of 12 items.

CONCLUSIONS

The number of people with dementia and their family caregivers is large and growing every day with the aging of the population. Living well with dementia is the goal. Current care systems are inadequate and lead to multiple poor outcomes. Innovative solutions like the DICE Approach with delivery methods including a manual and interactive training can put the key components of good dementia care at the fingertips of the people who need it most.

Nomenclature Used by Family Caregivers to Describe and Characterize Neuropsychiatric Symptoms

BACKGROUND AND OBJECTIVES

Neuropsychiatric symptoms (NPS) are a core feature of Alzheimer's disease and related dementias that are characterized by a fluctuating course. NPS are challenging to manage and contribute to high rates of burden among family caregivers. Successful information exchange between clinicians and family caregivers is critical for facilitating effective management of NPS. However, this communication is often challenging due to inconsistent terminology and classification of symptoms and limited understanding of how family caregivers recognize and describe symptoms. The objective of this study was to examine the language family caregivers' use to describe and contextualize NPS.

RESEARCH DESIGN AND METHODS

Descriptive qualitative study of 20 family caregivers in a mostly urban county in the Midwestern United States using semistructured interviews. Caregiver descriptions of NPS were analyzed using directed content and text analysis to examine terminology, followed by a thematic analysis approach to examine contextualization of NPS.

RESULTS

Caregivers employed shared terminologies to describe NPS that differed substantially from clinical terminology used to classify symptoms. Caregivers frequently engaged sense-making as a strategy to explain NPS. This sense-making served to contextualize patterns in behavior and was characterized by explanatory, situational, and strategy-oriented frameworks for understanding behavior in terms of its purpose and meaning. Caregivers' descriptions of NPS reflected broad overlap between individual NPS (i.e., agitation and care resistance) that would generally be considered clinically distinct symptoms.

DISCUSSION AND IMPLICATIONS

Nomenclature surrounding NPS may vary considerably between family caregivers and clinicians, and should be evaluated in partnership with people with dementia and their caregivers to ensure supportive interventions and resources are responsive to caregivers' interpretation of symptoms and sense-making.

Family Caregiving for Older Adults

Family members are the primary source of support for older adults with chronic illness and disability. Thousands of published empirical studies and dozens of reviews have documented the psychological and physical health effects of caregiving, identified caregivers at risk for adverse outcomes, and evaluated a wide range of intervention strategies to support caregivers. Caregiving as chronic stress exposure is the conceptual driver for much of this research. We review and synthesize the literature on the impact of caregiving and intervention strategies for supporting caregivers. The impact of caregiving is highly variable, driven largely by the intensity of care provided and the suffering of the care recipient. The intervention literature is littered with many failures and some successes. Successful interventions address both the pragmatics of care and the emotional toll of caregiving. We conclude with both research and policy recommendations that address a national agenda for caregiving.

Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD.

OBJECTIVE

This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center.

DESIGN, SETTING, AND PARTICIPANTS

Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017.

OUTCOME MEASUREMENTS

Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia.

RESULTS

Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89).

CONCLUSION

Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.

Implementation effectiveness of psychosocial and environmental care practices in assisted living

Psychosocial and environmental care practices are recommended to address behavioral expressions in persons with dementia, but their use has been limited partly because guidance is lacking regarding implementation. In response, we developed a simple "how-to" guide of evidence-based protocols for aromatherapy, natural light, familiar music, and robotic pets; trained staff in four assisted living (AL) communities to use the practices; provided materials; met with them regularly; and evaluated fidelity, facilitators and barriers to implementation, and staff knowledge, attitudes, and self-efficacy. After two months, staff reported more familiarity, confidence, and use; barriers such as difficulty locating supplies and task-focused staff with limited time; and staff "champion" facilitators. Notable differences were identified across communities, suggesting that just as care to individuals must be person-centered, practices embraced by communities must fit that community. Through strategic adoption, successful implementation is possible. The "how-to" guide is appropriate for AL, nursing homes, and persons' own homes.

Lessons learned from the statewide implementation of the Music & Memory program in nursing homes in Wisconsin in the USA

The movement of evidence-based interventions into institutional settings such as nursing homes is challenging. Among ecopsychosocial interventions to address behavioral problems of nursing home residents with dementia, Music and Memory, a popular intervention that provides individualized music listening, has shown potential to improve residents' quality of life. In Wisconsin in the USA, the Music and Memory program has been implemented in nursing home facilities statewide. In the present study, to examine facilitators and barriers related to implementation and sustainability of the Music and Memory program, all nursing homes in Wisconsin were invited to participate in a survey (online or mail). A total of 161 facilities participated, representing a response rate of 41%. Descriptive statistics and content analysis were conducted. Over 80% of responding facilities were providing the Music and Memory program, and 86% of those facilities planned to continue its use. The majority of respondents found Music and Memory to be beneficial to residents, but they also reported that the program was not equally effective for everyone and that it was time and labor intensive. Barriers to sustainability included lack of buy-in by direct care staff, use of technology, costs of equipment, inconsistency of volunteers, and families not supportive or helpful. Facilitators included support of facility personnel, family, and volunteers; observing positive effects of program; Music and Memory training provision and support; and accessibility of equipment. For the program to be successful, facilities must identify the residents most likely to benefit from it, realistically estimate its costs and required labor, and ensure staff buy-in.

Impacts of dance on agitation and anxiety among persons living with dementia: An integrative review

INTRODUCTION

Individuals living with dementia are likely to experience one or more neuropsychiatric symptoms on a daily basis. Dance has the potential to positively impact and reduce these symptoms. This integrative review was conducted to identify the impacts of dance on agitation and anxiety among those living with dementia.

METHODS

An integrative review methodology guided the literature search and evaluation. Thirty-Nine papers were retrieved from the initial search. Five studies were included in the review. The Mixed Methods Appraisal Tool was used to assess the quality of relevant articles.

RESULTS

Three quantitative and 2 qualitative studies were reviewed. Three out of 4 studies found dance positively impacted agitation. While 1 out of 2 studies reported improvements in anxiety.

DISCUSSION

This review suggests that dance has the potential to impact anxiety and agitation symptoms of persons living with dementia. However, the evidence is weak and further research is warranted.

Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: Two years follow-up

The management of neuropsychiatric symptoms is a challenge in long-term care facilities. Our objective was to assess the perception of telemedicine, as a useful tool to connect staff to specialized units. In this multicenter prospective study, 90 patients from ten facilities benefited from 180 sessions over two years. The primary outcome was the perception of telemedicine evaluated through semi-structured interviews at baseline and two years later. Our results revealed positive perceptions of telemedicine, confirmed after two years of real-life experience with its use. Not only do staff members believe that telemedicine is not a downgraded version of medicine, but they also believe that it could improve the quality of care. They expressed a very positive sense of recognition of their professional qualifications and indicated their need to be involved in change processes to ensure successful implementation and better adherence to telemedicine as a service.

A web-based training program for direct care workers in long-term care communities: Providing knowledge and skills to implement a music and memory intervention

As dementia increases and the availability of at-home caregivers decreases, the need grows for effective training for direct care workers. Direct care workers have demanding schedules with restrictive availability and lack professional incentives to pursue specialized training. This study explored the impact of the Mason Music & Memory Initiative (M³I), a web-based, micro-learning training for direct care workers, combined with the implementation of the Music & Memory intervention. The training provided a foundational understanding of dementia and the person-centered music intervention. Twenty-five direct care workers, across two long-term care communities, completed the training modules over four weeks. All participants completed a pre- and posttest, determining their knowledge and understanding of dementia and the Music & Memory intervention adopted by their facilities. Many workers found the training to be informative and inspiring, noting improved behaviors in residents during the implementation of the M³I.