Nonpharmacologic management of behavioral symptoms in dementia

Evaluation and management of the elderly patient presenting with cognitive complaints

Cognitive complaints are common in the geriatric population. Older adults should routinely be asked about any concerns about their memory or thinking, and any cognitive complaint from the patient or an informant should be evaluated rather than be attributed to aging. Several screening instruments are available to document objective impairments and guide further evaluation. Management goals for patients with cognitive impairment are focused on maintaining function and independence, providing caregiver support, and advance care planning. There are currently no treatments to effectively prevent or treat dementia. Increasing appreciation of the heterogeneity of Alzheimer disease may lead to novel treatment approaches.

Translating Evidence-Based Dementia Caregiving Interventions into Practice: State-of-the-Science and Next Steps

Over the past 3 decades, more than 200 dementia caregiver interventions have been tested in randomized clinical trials and found to be efficacious. Few programs have been translated for delivery in various service contexts, and they remain inaccessible to the 15+ million dementia family caregivers in the United States. This article examines translational efforts and offers a vision for more rapid advancement in this area. We summarize the evidence for caregiver interventions, review published translational efforts, and recommend future directions to bridge the research-practice fissure in this area. We suggest that as caregiver interventions are tested external to service contexts, a translational phase is required. Yet, this is hampered by evidentiary gaps, lack of theory to understand implementation challenges, insufficient funding and unsupportive payment structures for sustaining programs. We propose ways to advance translational activities and future research with practical applications.

Medication development for agitation and aggression in Alzheimer disease: review and discussion of recent randomized clinical trial design

BACKGROUND

The management of disruptive neuropsychiatric symptom (NPS) such as agitation and aggression (A/A) is a major priority in caring for people with Alzheimer's disease (AD). Few effective pharmacological or non-pharmacological options are available. Results of randomized clinical trials (RCTs) of drugs for A/A have been disappointing. This may result from the absence of biological efficacy for medications tested in treating A/A. It may also be related to methodological issues such as the choice of outcomes. The aim of this review was to highlight key methodological issues pertaining to RCTs of current and emerging medications for the treatment of A/A in AD.

METHODS

We searched PubMed/Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for RCTs comparing medications with either placebo or other drugs in the treatment of A/A in AD, between January 2008 and December 2013.

RESULTS

We identified a total of 18 RCTs; of these, 11 were completed and 7 ongoing. Of the ongoing RCTs, only one is in Phase III. Seven of 10 completed RCTs with reported results did not report greater benefit from drug than placebo. Each of the completed RCTs used a different definition of "clinically significant A/A." There was considerable heterogeneity in study design. The primary endpoints were largely proxy-based but a variety of scales were used. The definition of caregiver and scales used to assess caregiver outcomes were similarly heterogeneous. Placebo response was notable in all trials.

CONCLUSIONS

This review highlights a great heterogeneity in RCTs design of drugs for A/A in AD and some key methodological issues such as definition of A/A, choice of outcome measures and caregiver participation that could be addressed by an expert consensus to optimize future trials design.

Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition

BACKGROUND

Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome. The International Psychogeriatric Association formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs.

METHODS

The ADWG developed a transparent process using a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process.

RESULTS

Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as "strongly agree" or "somewhat agree" (68-88% across elements). A majority of the respondents agreed that the definition is appropriate for clinical and research applications.

CONCLUSIONS

A provisional consensus definition of agitation has been developed. This definition can be used to advance interventional and non-interventional research of agitation in patients with cognitive impairment.

The Home-Based Occupational Therapy Intervention in the Alzheimer's Disease Multiple Intervention Trial (ADMIT)

There is no way to prevent functional declines related to Alzheimer's Disease (AD). The use of occupational therapy (OT) has been shown to be successful in managing some aspects of AD. We added home-based OT to evidence-based best practice for AD with the aim of delaying functional decline in people with AD. OT was delivered in the home to a caregiver dyad including the person with AD and her/his caregiver. This paper describes the OT intervention for the AD Multiple Intervention Trial, a parallel randomized controlled trial. We include baseline data on the 180 caregiver dyads.

Antipsychotic Use in a Diverse Population With Dementia: A Retrospective Review of the National Alzheimer's Coordinating Center Database

A cross-sectional analysis examined medication records in the National Alzheimer's Coordinating Center Database for community-dwelling patients with dementia who visited an Alzheimer's Disease Center between 2008 and 2014. Hispanic participants had a 1.62-fold greater use of antipsychotic medications, which was largely accounted for by a higher prevalence of neuropsychiatric symptoms and more severe dementia compared with non-Hispanic whites. These results are consistent with reports of later transition to nursing home care among Hispanic participants. Further studies are needed to clarify ethnic differences in how families and physicians address dementia progression and neuropsychiatric symptoms in community-dwelling patients with dementia.

Sintomas neuropsiquiátricos na doença de Alzheimer: frequência, correlação e ansiedade do cuidador

INTRODUÇÃO: Sintomas neuropsiquiátricos ocorrem em 80-90% dos pacientes com demência, interferem significativamente na autonomia do paciente e ocasionam alta carga física, financeira e emocional ao núcleo familiar, resultando em institucionalização precoce. OBJETIVOS: Identificar sintomas neuropsiquiátricos mais frequentes e de maior gravidade nos pacientes portadores da doença de Alzheimer; especificar quais distúrbios são descritos como mais desgastantes pelo cuidador; e correlacionar os sintomas neuropsiquiátricos. MÉTODOS: Realizou-se estudo transversal, descritivo e exploratório, durante um ano, com idosos com provável doença de Alzheimer, atendidos no ambulatório de geriatria de uma instituição filantrópica de Vitória, que estavam acompanhados do principal cuidador. As duas subescalas brasileiras do Inventário Neuropsiquiátrico foram aplicadas ao acompanhante, e os sintomas foram correlacionados utilizando a correlação de Pearson e Spearman. RESULTADOS: Nos 50 pacientes analisados, o comportamento motor aberrante foi a manifestação mais frequente, enquanto a agitação apresentou maior gravidade entre os pacientes e foi relatada como o sintoma mais desgastante pelos cuidadores, que eram, predominantemente, filhas. Múltiplas correlações entre sintomas foram encontradas, sendo muito fortes: delírio e alucinação; delírio e ansiedade; delírio e disforia; agitação e irritabilidade. CONCLUSÃO: Os resultados reforçam a necessidade de estudos voltados para a abordagem das manifestações neuropsiquiátricas, dada sua alta prevalência e à presença de sintomas concomitantes que geram alto grau de desgaste no cuidador.

From rural to urban areas: differences in behavioural and psychological symptoms of dementia in nursing home residents according to geographical location

BACKGROUND

We determined whether the prevalence of behavioural and psychological symptoms of dementia (BPSD) in institutionalized older adults differed according to the geographical location of different facilities.

METHODS

This cross-sectional study covered 175 nursing homes (NH) in France (n = 6275; age, 86.0 ± 8.2 years; women, 73.7%). Information on NH residents' health status and NH structure and internal organization were recorded by the NH staff. Each participant was coded for the presence or absence of the following BPSD: aggressive, screaming, and wandering behaviours. NH were geographically defined as rural (<2000 inhabitants), low urban (2000 ≤ inhabitants < 10 000), intermediate urban (10 000 ≤ inhabitants < 100 000), or high urban (inhabitants ≥ 100 000).

RESULTS

Adjusted binary logistic regressions showed that, compared with residents living in rural NH, those living in NH located in high-urban areas had a significantly higher risk of aggressiveness (odds ratio = 1.33; 95% confidence interval = 1.06-1.67) and screaming (odds ratio = 1.43; 95% confidence interval = 1.05-1.95). The likelihood of aggressiveness was also higher in residents living in NH located in intermediate-urban areas (odds ratio = 1.36; 95% confidence interval = 1.13-1.65).

CONCLUSIONS

Rurality seems to play a positive role in the expression of BPSD. If this hypothesis were confirmed, it would encourage NH staff to develop activities that explore rural potentials for the management of BPSD.

Management of Behavioral and Psychological Symptoms of Dementia

Symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia are defined as the term "Behavioral and Psychological Symptoms of Dementia (BPSD)." The behavioral symptoms of dementia include physical/verbal aggression, agitation, disinhibition, restlessness, wandering, culturally inappropriate behaviors, sexual disinhibition, and hoarding, and the psychological symptoms of dementia are anxiety, depressive mood, hallucinations and delusions, apathy, and misidentification syndrome. With the cognitive decline in Alzheimer's Dementia (AD), the frequency of neuropsychiatric symptoms increases. Apathy, depression, irritability, agitation, and anxiety are the most frequently detected neuropsychiatric symptoms of AD. In the mild stage of AD, affective symptoms are more likely to occur; agitated and psychotic behaviors are frequent in patients with moderately impaired cognitive function. When neuropsychiatric symptoms are first detected, medical conditions, such as delirium, infection, dehydration, diarrhea, and drug interactions, must be ruled out. The treatment of mild BPSD must be started with psychosocial approaches, such as behavioral management, caregiver education, and physical activity. Medications are indicated for BPSD symptoms that are refractory to non-pharmacological interventions or severe or jeopardizing the safety of a patient or others, often in conjunction with non-pharmacological interventions.

Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures

BACKGROUND

Neuropsychiatric symptoms (NPS) occur in people with dementia throughout disease course and across etiologies. NPS are associated with significant morbidities and hastened disease processes. Nevertheless, people with dementia are not systematically assessed for NPS in clinical settings. We review existing NPS measures for clinical and/or research purposes, and identify measurement gaps.

METHODS

We conducted a computerized search of peer-reviewed published studies of measures (January 1, 1980-December 1, 2013) using multiple search terms. Measures selected for review were in English, had adequate psychometric properties, and were developed for or used with people with dementia. Papers describing measures were evaluated by three coders along seven characteristics: behavioral domains, number of items, method of administration, response categories, targeted population, setting, and psychometric properties.

RESULTS

Overall, 2,233 papers were identified through search terms, and 36 papers from manual searches of references. From 2,269 papers, 85 measures were identified of which 45 (52.9%) had adequate psychometric properties and were developed or used with dementia populations. Of these, 16 (35.6%) were general measures that included a wide range of behaviors; 29 (64.4%) targeted specific behaviors (e.g. agitation). Measures differed widely as to behaviors assessed and measurement properties.

CONCLUSIONS

A robust set of diverse measures exists for assessing NPS in different settings. No measures identify risk factors for behaviors or enable an evaluation of the context in which behaviors occur. To improve clinical efforts, research is needed to evaluate concordance of behavioral ratings between formal and informal caregivers, and to develop and test measures that can identify known risks for behaviors and the circumstances under which behaviors occur.

Palliative care as a primary therapeutic approach in advanced dementia: a narrative review

PURPOSE

The goal of this narrative review was to identify and summarize the ways in which palliative care could benefit patients who have advanced dementia.

METHODS

This case-based discussion article examines current literature on palliative care for dementia.

FINDINGS

Dementia is an incurable, progressive disease that affects millions of subjects. The prevalence has grown in the last decade and is projected to continue on this trajectory. In the later stages of dementia, subjects require increasing levels of care due to severe cognitive and functional impairment. Although the field of palliative medicine focuses on improving the quality of life of patients with life-limiting illnesses, many patients with advanced dementia do not receive palliative care services.

IMPLICATIONS

Palliative care has been shown to improve patient and caregiver satisfaction, quality of life, and symptom burden at the end of life. Patients with advanced dementia would benefit from increased access to palliative care.

Sleep disorders and fatigue: special issues in the older adult with cancer

Older adults with cancer reporting fatigue and sleep disorders often have coexisting geriatric syndromes and are at high risk of further functional decline. This review summarizes special considerations in the diagnosis and treatment of sleep disorders and fatigue when older persons with cancer present with multiple comorbidities, polypharmacy, dementia, delirium, and/or falls. Physicians caring for these older adults need to be aware of the unique diagnostic and treatment concerns in this population so that these patients can receive optimal care.

Anxiety and stigma in dementia: a threat to aging in place

The number of Americans with dementia is expected to increase as the population ages. Developing dementia is feared by many older adults and may result in anxiety in persons with dementia. This article focuses on anxiety, one of the least understood symptoms associated with dementia in community-dwelling older adults, the stigma of dementia, and the relationship between anxiety and stigma in dementia. When undetected and untreated, anxiety and associated stigma can adversely affect quality of life and the ability to age in place.

Antipsychotic use in elderly patients with dementia: Efficacy and safety concerns

Behavioral and psychiatric symptoms of dementia (BPSD) refer to a heterogeneous group of symptoms that represent non-cognitive complications of Alzheimer's disease (AD) and other dementias. Currently, there are no FDA-approved antipsychotic medications for management of BPSD in the United States. Second generation antipsychotics (SGAs) should only be used for appropriate and justified BPSD targets including distressing and severe physical aggression and/or disturbing hallucinations or delusions that pose a risk of harm to self or others after non-pharmacologic interventions have failed. At best, SGAs provide only modest effects and are associated with increased risk for mortality and cerebrovascular complications in addition to other agent-specific side effects. Current evidence and recommendations support use of risperidone, aripiprazole or olanzapine for Alzheimer's disease (AD) and vascular dementia (VaD), and use of quetiapine or clozapine for Lewy body dementia (LBD) and Parkinson's disease dementia (PDD). Any SGA should be initiated at low dosages with slow titration; and the lowest effective dose should be used as a maintenance dose only for a short period of time. Patients should be monitored for clinical response and adverse effects and should be periodically evaluated for continued need for medication. Appropriate use of SGAs for management of BPSD is critical to increase safety for our growing elderly population with dementia.

Minimizing confusion and disorientation: cognitive support work in informal dementia caregiving

Drawing from ethnographic fieldwork and in-depth interviews, I explain how informal dementia caregivers attempt to reduce the affected individual's moments of confusion and disorientation through cognitive support work. I identify three stages through which such support takes shape and then gradually declines in usage. In a first stage, family members collaborate with affected individuals to first identify and then to avoid "triggers" that elicit sudden bouts of confusion. In a second stage, caregivers lose the effective collaboration of the affected individual and begin unilateral attempts to minimize confused states through pre-emptive conversational techniques, third-party interactional support, and social-environment shifts. In a third stage, caregivers learn that the affected individual has reached a level of impairment that does not respond well to efforts at reduction and begin abandoning strategies. I identify the motivations driving cognitive support work and discuss the role of lay health knowledge in dementia caregiving. I conclude by considering the utility of cognitive support work as a concept within dementia caregiving.

Impairments in experience-dependent scaling and stability of hippocampal place fields limit spatial learning in a mouse model of Alzheimer's disease

Impaired spatial memory characterizes many mouse models for Alzheimer's disease, but we understand little about how this trait arises. Here, we use a transgenic model of amyloidosis to examine the relationship between behavioral performance in tests of spatial navigation and the function of hippocampal place cells. We find that amyloid precursor protein (APP) mice require considerably more training than controls to reach the same level of performance in a water maze task, and recall the trained location less well 24 h later. At a single cell level, place fields from control mice become more stable and spatially restricted with repeated exposure to a new environment, while those in APP mice improve less over time, ultimately producing a spatial code of lower resolution, accuracy, and reliability than controls. The limited refinement of place fields in APP mice likely contributes to their delayed water maze acquisition, and provides evidence for circuit dysfunction underlying cognitive impairment.

Recruiting Community-Based Dementia Patients and Caregivers in a Nonpharmacologic Randomized Trial: What Works and How Much Does It Cost?

OBJECTIVES

The aim of this study was to evaluate the yield and cost of three recruitment strategies-direct mail, newspaper advertisements, and community outreach-for identifying and enrolling dementia caregivers into a randomized trial testing a nonpharmacologic approach to enhancing quality of life of patients and caregivers (dyads).

METHOD

Enrollment occurred between 2006 and 2008. The number of recruitment inquiries, number and race of enrollees, and costs for each recruitment strategy were recorded.

RESULTS

Of 284 inquiries, 237 (83%) dyads enrolled. Total cost for recruitment across methodologies was US$154 per dyad. Direct mailings resulted in the most enrollees (n = 135, 57%) and was the least costly method (US$63 per dyad) compared with newspaper ads (US$224 per dyad) and community outreach (US$350 per dyad). Although enrollees were predominately White, mailings yielded the highest number of non-Whites (n = 37).

DISCUSSION

Direct mailings was the most effective and least costly method for enrolling dyads in a nonpharmacologic dementia trial.

Best practices interventions to improve quality of care of people with dementia living at home

OBJECTIVE

To identify effective interventions which improve quality of care for people with dementia (PwD) living at home.

METHODS

MEDLINE-(via PubMed), CINAHL, PsycINFO and ISI Web of Science databases were searched.

INCLUSION CRITERIA

(1) randomized controlled trials; (2) published in English-language, peer-reviewed journals between 1990 and 2012; (3) evaluated strategies to improve quality of care for PwD cared at home; and (4) participants older than 65.

RESULTS

23 studies met inclusion criteria. All the studies aimed to improve PwD quality of care and most of them focused on PwD caregivers. Psychoeducational programs are the most frequently assessed interventions and multicomponent interventions produced the most promising results.

CONCLUSION

Due to the great variety of interventions describing specific samples and contexts, comparison of practice effectiveness is difficult. However, cognitive rehabilitation in PwD is effective when applied at an early stage of the disease. Case managers have demonstrated to reduce PwD institutionalization and the use of other community services. The studies were limited by sample heterogeneity, short follow-up or insufficiently detailed description.

PRACTICE IMPLICATIONS

To improve PwD homecare, health professionals should educate and support caregivers. Before specific interventional recommendations can be made, further research addressing the limitations of current studies is needed.

Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel

Noncognitive neuropsychiatric symptoms (NPS) of dementia (aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, disinhibition) affect individuals with dementia nearly universally across dementia stages and etiologies. NPS are associated with poor outcomes for individuals with dementia and caregivers, including excess morbidity and mortality, greater healthcare use, and earlier nursing home placement, as well as caregiver stress, depression, and difficulty with employment. Although the Food and Drug Administration has not approved pharmacotherapy for NPS, psychotropic medications are frequently used to manage these symptoms, but in the few cases of proven pharmacological efficacy, significant risk of adverse effects may offset benefits. There is evidence of efficacy and limited potential for adverse effects of nonpharmacological treatments, typically considered first line, but their uptake as preferred treatments remains inadequate in real-world clinical settings. Thus, the field currently finds itself in a predicament in terms of management of these difficult symptoms. It was in this context that the University of Michigan Program for Positive Aging, working in collaboration with the Johns Hopkins Alzheimer's Disease Research Center and Center for Innovative Care in Aging sponsored and convened a multidisciplinary expert panel in Detroit, Michigan, in fall 2011 with three objectives: to define critical elements of care for NPS in dementia; to construct an approach describing the sequential and iterative steps of managing NPS in real-world clinical settings that can be used as a basis for integrating nonpharmacological and pharmacological approaches; and to discuss how the approach generated could be implemented in research and clinical care.

Quality improvement in neurology: dementia management quality measures

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer's Project Act in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer's disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.

Factors associated with caregiver readiness to use nonpharmacologic strategies to manage dementia-related behavioral symptoms

BACKGROUND

Nonpharmacologic strategies to manage dementia-related behavioral symptoms depend upon caregiver implementation. Caregivers may vary in readiness to use strategies. We examined characteristics associated with readiness, extent readiness changed during intervention, and predictors of change in readiness.

METHODS

Data came from a randomized trial involving 119 caregivers in a nonpharmacologic intervention for managing behavioral symptoms. Baseline measures included caregiver, patient, and treatment-related factors. At initial (2 weeks from baseline) and final (16 weeks) intervention sessions, interventionists rated caregiver readiness as pre-action (precontemplation = 1; contemplation = 2; preparation = 3) or action (= 4). Ordinal logistic regression identified baseline characteristics associated with initial readiness. Mc Nemar-Bowker test of symmetry described change in readiness; binary logistic regression identified baseline predictors of change in readiness (initial to final sessions). One-way multivariate analysis of variance identified treatment factors (dose/intensity, number of strategies used, perceived benefits, and therapeutic engagement) associated with change in readiness.

RESULTS

At initial intervention session, 67.2% (N = 80) of caregivers were in pre-action and 32.8% (N = 39) in action. Initial high readiness was associated with better caregiver mood, less financial difficulty, lower patient cognition, and more behavioral symptoms. By final session, 72% (N = 79) were in action and 28% (N = 31) in pre-action; caregivers with less financial difficulty improved in readiness (B = -0.70, p = 0.017); those in action were more therapeutically engaged (F[2,107] = 3.61, p = 0.030) and perceived greater intervention benefits (F[2, 88] = 6.06, p = 0.003).

CONCLUSION

Whereas patient and caregiver-related factors were associated with initial readiness, financial stability, therapeutic engagement, and perceived benefits enhanced probability of change. Understanding caregiver readiness and factors associated with its change may be important considerations in nonpharmacologic interventions.

The role of the occupational therapist in the management of neuropsychiatric symptoms of dementia in clinical settings

Neuropsychiatric symptoms (NPS) of dementia include aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, and disinhibition. NPS affect dementia patients nearly universally across dementia stages and etiologies. They are associated with poor patient and caregiver outcomes, including increased health care utilization, excess morbidity and mortality, and earlier nursing home placement, as well as caregiver stress, depression and reduced employment. There are no FDA-approved medications for NPS, but it is a common clinical practice to use psychotropic medications such as antipsychotics, to control symptoms; however, antipsychotics show only modest efficacy in improving NPS and have significant risks for patients, including side effects and mortality. Nonpharmacologic treatments are considered first-line by multiple medical bodies and expert consensus, as they show evidence for efficacy and have limited potential for adverse effects. Ideally, nonpharmacological management of NPS in clinical settings occurs in multidisciplinary teams, where occupational therapists play an important collaborative role in the care of the person with dementia. Our group has articulated an evidence-informed structured approach to the management of NPS that can be integrated into diverse practice settings and used by providers of various disciplines. The "DICE" (Describe, Investigate, Create, and Evaluate) approach is inherently patient- and caregiver-centered, as patient and caregiver concerns are integral to each step of the process. DICE offers a clinical reasoning approach through which providers can more efficiently and effectively choose optimal treatment plans. The purpose of this paper is to describe the role of the occupational therapy in using the DICE approach for NPS management.

Severe agitation in severe early-onset Alzheimer's disease resolves with ECT

Dementia-related behavioral disturbances are mostly treated with antipsychotics; however, the observed beneficial effects are modest and the risk of serious adverse effects high. We report the case of a 57-year-old woman with severe early-onset Alzheimer's disease and severe agitation, whom we treated with electroconvulsive therapy (ECT). A significant clinical improvement was achieved over eight ECT sessions, which were tolerated well without cognitive worsening, and lasted approximately 3 months. Our case demonstrates the safe and effective use of ECT in pharmacotherapy-resistant severe agitation in Alzheimer's disease. The risk-benefit profile of ECT for dementia-related agitation should be further investigated in clinical trials.

Quality improvement in neurology: dementia management quality measures (executive summary)

This article represents the efforts of an interdisciplinary work group, the Dementia Measures Work Group (DWG), composed of representatives of diverse national organizations who convened specifically to define optimal standards of dementia care for individual practitioners as well as multidisciplinary teams. The DWG measurement set includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care prior to the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments for tracking patient-centered outcomes. In addition, it specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as patients.

A non-pharmacologic approach to address challenging behaviors of Veterans with dementia: description of the tailored activity program-VA randomized trial

Background

Behavioral symptoms accompanying dementia are associated with increased health care costs, reduced quality of life and daily functioning, heightened family caregiver burden, and nursing home placement. Standard care typically involves pharmacologic agents, but these are, at best, modestly effective, carry serious risks, including mortality, and do not address behavioral symptoms families consider most distressful and which may prompt nursing home placement. Given dementia’s devastating effects and the absence of an imminent cure, the Veterans Administration has supported the development and testing of new approaches to manage challenging behaviors at home.

Methods/Design

The Tailored Activity Program – Veterans Administration is a Phase III efficacy trial designed to reduce behavioral symptoms in Veterans with dementia living with their caregivers in the community. The study uses a randomized two-group parallel design with 160 diverse Veterans and caregivers. The experimental group receives a transformative patient-centric intervention designed to reduce the burden of behavioral symptoms in Veterans with dementia. An occupational therapist conducts an assessment to identify a Veteran’s preserved capabilities, deficit areas, previous roles, habits, and interests to develop activities tailored to the Veteran. Family caregivers are then trained to incorporate activities into daily care. The attention-control group receives bi-monthly telephone contact where education on topics relevant to dementia is provided to caregivers. Key outcomes include reduced frequency and severity of behavioral symptoms using the 12-item Neuropsychiatric Inventory (primary endpoint), reduced caregiver burden, enhanced skill acquisition, efficacy using activities, and time spent providing care at 4 months; and long-term effects (8 months) on the Veteran’s quality of life and frequency and severity of behavioral symptoms, and caregiver use of activities. The programs’ impact of Veterans Administration cost is also examined. Study precision will be increased through face-to-face research team trainings with procedural manuals and review of audio-taped interviews and intervention sessions.

Discussion

The Tailored Activity Program – Veterans Administration is designed to improve the quality of life of Veterans with dementia and lessen the burden of care on caregivers. Activities are tailored to reflect the Veteran’s preserved capabilities and interests to enhance active engagement, while not taxing areas of cognition that are most impaired.

Trial registration

ClinicalTrials.gov, NCT01357564

Clinical implications of the new diagnostic guidelines for dementia

New criteria have been proposed for diagnosing Alzheimer's disease. These emphasize that this illness exists on a continuum and begins early on. This article reviews the pros and cons of these criteria. It also provides practical guidelines for psychiatrists whose patients may be affected by these new criteria. Particular attention is given to patients who, as opposed to their wanting to know whether they are likely to have AD, want to deny this possibility.