Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards

A meta-review and synthesis of the effectiveness of psychosocial interventions for people living with dementia nearing the end of life and their family carers

BACKGROUND

Dementia, is a leading cause of death internationally, affecting 55 million people. A palliative approach, emphasizing holistic and psychosocial care, is increasingly recognised as essential for addressing the complex needs of people with dementia and their carers. However, little research has explored the interface between psychosocial interventions for people with dementia near the end of life and palliative care, necessitating a synthesis to guide integrated, person-centred care.

AIM

To establish a framework of evidence-based psychosocial interventions in dementia palliative care.

METHODS

We conducted a systematic review using narrative synthesis. Three electronic databases (Epistemonikos, MEDLINE and ASSIA) were searched (January 1980-May 2024), for systematic reviews, guided by the methods of Cochrane overview of reviews. This is part of a series of reviews with the focus for this manuscript on psychosocial interventions for people with dementia.

RESULTS

Thirty-four reviews were included, published between 2009 and 2023. No reviews of interventions covered all domains of dementia palliative care. The majority focussed on neuropsychiatric symptom management and promoting wellbeing. There were no reviews which covered managing care transitions, continuity of care and care co-ordination, or information for people with dementia.

CONCLUSIONS

There is significant progress in the development and evaluation of interventions targeting behavioural and psychological symptoms of dementia (BPSD). However, a critical gap persists in addressing other essential aspects of quality of life and dementia care, with a notable gap in addressing many crucial aspects of palliative dementia care, such as care co-ordination, transitions, and carer support.

Group Reminiscence Therapy for Dementia to Improve Well-Being and Reduce Behavioral Symptoms

The global increase in dementia cases highlights the urgent need for effective treatment and care strategies. The aim of this study was to evaluate the effects of group reminiscence therapy on cognitive function, subjective well-being, and behavioral and psychological symptoms of dementia (BPSD) in older adults with moderate to severe dementia. A pre-post comparative design was used, with 49 participants receiving eight group reminiscence therapy sessions over 4 weeks. Baseline, one-week, and one-month postintervention assessments were conducted using the Hasegawa Dementia Scale-Revised (HDS-R), the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), and the Philadelphia Geriatric Center Morale Scale (PGC Morale Scale). The results showed no significant improvement in HDS-R scores, but significant improvements in PGC Morale Scale (p = 0.0417) and NPI-NH scores (p = 0.00226), indicating improved well-being and reduced BPSD. These findings suggest that group reminiscence therapy is effective in improving BPSD. Future research should focus on extending the duration of the intervention, including different populations, and combining group reminiscence therapy with other therapeutic approaches to fully determine its long-term benefits and mechanisms. Research on its cost-effectiveness and cultural applicability could further validate and improve the use of group reminiscence therapy in diverse care settings.

The dangerous "West Coast Swing" by hyperglycaemia and chronic stress in the mouse hippocampus: Role of kynurenine catabolism

Growing epidemiological studies highlight a bi-directional relationship between depressive symptoms and diabetes mellitus. However, the detrimental impact of their co-existence on mental health suggests the need to treat this comorbidity as a separate entity rather than the two different pathologies. Herein, we characterized the peculiar mechanisms activated in mouse hippocampus from the concurrent development of hyperglycaemia, characterizing the different diabetes subtypes, and chronic stress, recognized as a possible factor predisposing to major depression. Our work demonstrates that kynurenine overproduction, leading to apoptosis in the hippocampus, is triggered in a different way depending on hyperglycaemia or chronic stress. Indeed, in the former, kynurenine appears produced by infiltered macrophages whereas, in the latter, peripheral kynurenine preferentially promotes resident microglia activation. In this scenario, QA, derived from kynurenine catabolism, appears a key mediator causing glutamatergic synapse dysfunction and apoptosis, thus contributing to brain atrophy. We demonstrated that the coexistence of hyperglycaemia and chronic stress worsened hippocampal damage through alternative mechanisms, such as GLUT-4 and BDNF down-expression, denoting mitochondrial dysfunction and apoptosis on one hand and evoking the compromission of neurogenesis on the other. Overall, in the degeneration of neurovascular unit, hyperglycaemia and chronic stress interacted each other as the partners of a "West Coast Swing" in which the leading role can be assumed alternatively by each partner of the dance. The comprehension of these mechanisms can open novel perspectives in the management of diabetic/depressed patients, but also in the understanding the pathogenesis of other neurodegenerative disease characterized by the compromission of hippocampal function.

Young-onset dementia diagnosis, management and care: a narrative review

Young-onset dementia comprises a heterogeneous range of dementias, with onset at less than 65 years of age. These include primary dementias such as Alzheimer disease, frontotemporal and vascular dementias; genetic/familial dementias; metabolic disorders; and secondary dementias such as those that result from alcohol use disorder, traumatic brain injury, and infections. The presentation of young-onset dementia is varied and may include cognitive, psychiatric and neurological symptoms. Diagnostic delay is common, with a frequent diagnostic conundrum being, "Is this young-onset dementia or is this psychiatric?". For assessment and accurate diagnosis, a thorough screen is recommended, such as collateral history and investigations such as neuroimaging, lumbar puncture, neuropsychology, and genetic testing. The management of young-onset dementia needs to be age-appropriate and multidisciplinary, with timely access to services and consideration of the family (including children).

Complementary and integrative medicines for behavioral and psychological symptoms of dementia: Overview of systematic reviews

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are major contributing factors to disease burden in dementia patients. Complementary and integrative medicine (CIM) has received attention in the management of dementia in patients with BPSDs. This overview aimed to comprehensively and critically review previous systematic reviews (SRs) of CIM modalities for BPSD management.

METHODS

Thirteen databases were searched in November 2021 to identify SRs on CIM for BPSDs. The methodological quality of the included studies was assessed using A MeaSurement Tool to Assess systematic Reviews 2.

RESULTS

Among 38 SRs, aromatherapy was the most commonly studied intervention, followed by herbal medicine (HM), acupuncture/acupressure, mindfulness-based interventions, relaxation, and Taichi. Half of the studies on aromatherapy reported significantly improved BPSDs, especially agitation, while the remainder reported mixed results/insufficient evidence. Most studies (85.71%) on HM supported its significant benefits in BPSDs. Yokukansan, an individual HM, was most frequently studied for BPSDs, with a significant beneficial effect on delusions, hallucinations, and agitation/aggression. Moreover, some meta-analyses supported the benefits of HM as an adjunct to psychotropic drugs in BPSD management. Other CIM interventions had insufficient clinical evidence. The methodological quality of the included studies was poor, and most were rated low or critically low (92.11%).

CONCLUSION

Aromatherapy, the most frequently investigated CIM for BPSD, had mixed results or insufficient evidence. HM, as an adjunct to psychotropic drugs including antipsychotics, exhibited additional benefits regarding the efficacy and safety for BPSDs. This overview emphasizes the requirement for greater quantity and quality of research in this field.

REGISTRATION NUMBER

Open Science Framework registry (g5f3m) (https://osf.io/g5f3m), PROSPERO (CRD42020211009) (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020211009).

Clinico-demographics of people with younger-onset dementia and neuropsychiatric symptoms referred to an Australian dementia support service: A comparison study with older-onset dementia

OBJECTIVE

Younger-onset dementia accounts for about 5-10% of all dementias in Australia. Little data is available on neuropsychiatric symptoms in people with younger-onset dementia compared to those with older-onset dementia. This study aims to compare the types of neuropsychiatric symptoms and their clinico-demographic characteristics of people with younger-onset dementia and older-onset dementia who are referred to a specific dementia support service.

METHODS

A 2-year retrospective observational cross-sectional analysis was undertaken on referrals with neuropsychiatric symptoms from Dementia Support Australia programmes. Neuropsychiatric symptoms were measured using the Neuropsychiatric Inventory total severity scores and distress scores. Contributing factors to neuropsychiatric symptoms for dementia groups were examined. Logistic regression was used to examine the relationship between individual neuropsychiatric symptoms and having older-onset dementia vs younger-onset dementia.

RESULTS

Of the 15,952 referrals, about 5% (n = 729, mean age: 60.7 years, standard deviation = 5.4) were individuals with younger-onset dementia. Referrals with older-onset dementia were more likely to be female (56%), whereas referrals with younger-onset dementia were more likely to be male (54%). There was a four times greater rate of frontotemporal dementia for those with younger-onset dementia (16.0%, n = 117) compared to those with older-onset dementia (2.8%, n = 427), χ² (1) = 366.2, p < 0.001. Referrals with younger-onset dementia were more likely to be referred from community settings and those with older-onset dementia were more likely to be from residential aged care. Overall, there was no difference in the severity and distress of neuropsychiatric symptoms between the two groups. Contributing factors to neuropsychiatric symptoms were different between the groups, with pain being more frequently endorsed for individuals with older-onset dementia whereas communication difficulties were more commonly identified for those with younger-onset dementia.

CONCLUSION

Clinico-demographics of referrals with younger-onset dementia differ from those with older-onset dementia. There were some differences in the characteristics of neuropsychiatric symptoms between younger-onset dementia and older-onset dementia. Our findings have implications for service provision and support for people with dementia at different ages.

Application of virtual reality for dementia management

Age is recognized as the major factors of dementia, especially in for Alzheimer’s disease (AD). Given to the aged population, the increased number of demented population has been receiving a great impact in our society. Unfortunately, so far, no cured medicines have been demonstrated to provide effective treatment in AD. The combination of pharmacological and non-pharmacological interventions has been proposed to manage dementia with potential benefits especially in decreasing caregiver’s burden and behavior, as well as psychological problems of demented patients. Recently, giving to the glorious development in digital technologies, the virtual reality, one of the non-pharmacological interventions has been used extensively in dementia managements for its strengths which can be adapted in accordance with the heterogeneous needs from demented patients and their caregivers. However, various study designs and other reasons made these results difficult to be interpreted. In this review our goal is to provide a better understanding for these points.

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.

A person-centered framework for designing music-based therapeutic studies in dementia: current barriers and a path forward

Objectives: Music-based interventions have received growing attention to improve quality of life for people diagnosed with dementia. Results of randomized controlled trials and meta-analytic reviews to date, however, reveal a lack of conclusive evidence for or against the effectiveness of such interventions. Herein, we critically review the basic assumptions and methodological issues ingrained in the cultures of research and care as they relate to evaluating music-based treatments for people with dementia, and propose a shift in the methodology by which music interventions are empirically evaluated.Method: We begin by reviewing existing barriers to achieving clarity on the effectiveness of music interventions, and we highlight methodological and sociocultural constraints that have limited our ability to reach concrete conclusions in research studies to-date. We then consider several key factors that have demonstrated relevance in matching people to specific music-based interventions. Based on these key factors, we developed a person-centered framework integrating elements from precision-medicine methodology to guide intervention studies.Results: Our organizing framework systematically integrates the following factors to inform the design of intervention studies: 1) person-centered goals and desired outcomes; 2) differences among individuals in clinical, cognitive, and historical attributes; and 3) the context of intervention and access to resources.Conclusion: Integration of the proposed framework into empirical investigations of music interventions for people living with dementia will inform precise and tailored interventions that will bring clarity to this growing body of research. Another aim of this framework is to foster a more humane, person-centered approach to our culture of care.

An Integrative Review of Behavioral Disturbances in Veterans With Dementia and PTSD

OBJECTIVE

Both posttraumatic stress disorder (PTSD) and dementia have been associated with a variety of behavioral changes; however, little is known about the behavioral consequences of comorbid PTSD and dementia. An integrative review was conducted to identify and examine studies reporting on behavioral disturbances in Veterans with PTSD and dementia.

METHODS

PubMed and PsychINFO databases were searched for articles on behavioral disturbances in Veterans with comorbid PTSD and dementia.

RESULTS

Seven studies met inclusion for this review, sampling a total of 822 Veterans. Preliminary findings suggest that though Veterans with dementia and comorbid PTSD may present with more difficult behavioral symptoms, they do not typically display increased levels of aggression.

CONCLUSION

Given the limited study inventory, the key finding from this review highlights the lack of methodologically rigorous empirical studies on this topic. A research agenda is proposed to encourage future studies to address gaps in the literature.

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.

Care for dementia patients and caregivers amid COVID-19 pandemic

BACKGROUND

Multiple efforts have been taken across the world to bridge gaps in evidence and provide recommendations for dementia care and caregiver support during the COVID-19 pandemic. We aimed to review the available literature on measures used to alleviate the negative impacts of the pandemic on dementia care.

METHODS

We searched three databases: PubMed, CINAHL and PsycINFO to identify studies that described strategies that were recommended or taken to provide care and support to persons with dementia and their caregivers during the COVID-19 pandemic.

RESULTS

We included a total of 37 papers, originating from high, middle and low-income countries. We also included 6 papers exploring safety of COVID-19 vaccinations. Infection prevention recommendations predominantly involved providing consistent reminders to persons with dementia to engage in infection prevention measures and included measures to restrict wandering in long-term care settings to reduce spread of infection. Medical care included tele and video consultations to maintain and monitor clinical stability. Guidance for continuing rehabilitation activities for persons with dementia through remotely conducted cognitive stimulating activities, physical exercises and environmental modifications were further highlighted by multiple studies/articles. In addition, strategies to support caregivers were also advised and included teleconsultations and psycho-educational programs.

CONCLUSION

The COVID-19 pandemic has exposed gaps in health and social care systems across the world, but has also revealed the enduring dedication of clinicians, expert groups and dementia support organizations to modify and adapt existing dementia care services to meet the needs of persons with dementia and their caregivers during periods of emergency.

Creating joy in the workplace

Creating a joyful workplace is not the same as dealing with issues of stress, fatigue, burn-out, and resilience. It requires a proactive approach to augment feelings of worth, appreciation, and well-being in the members of the team. The sense that one is pursuing worthwhile, valuable activities requires a wholesale commitment to the mission, vision and values of the organization. These tenets are often created through an organic consensus of collegial workmates and then put to action by a leadership team. Reassessing the goals and virtues of the organization at appropriate intervals leads to ongoing loyalty and commitment to the team and a positive attitude. Well-being is addressed through the creation of a bright and cheerful physical and psychosocial workplace that offers programs that encourage mindfulness, humor, playfulness, and fitful lifestyle choices. The sense that one's work is appreciated and valued stems from an attitude of gratitude on behalf of all levels of the organization including management and peers where such encouragement flourishes. Those expressions of appreciation may be in the form of celebrations in the workplace and/or compensation and benefits that appropriately value the contributions of the employee. The organization's executive team should be dedicated to crafting an environment that leads to delighted, healthy employees.

Psychosocial care in dementia in European higher education: Evidence from the SiDECar ("Skills in DEmentia Care") project

In dementia care, psychosocial interventions can increase people's quality of life with dementia and their caregivers. Despite their effectiveness, their translation into practice lacks the desirable systematicity. Systematic educational programs on psychosocial interventions in dementia will improve this translation, as it prepares professionals to face the complexity of dementia care. This study aimed to systematically map out the extent to which higher education programs in Europe include teaching activities about psychosocial care of dementia. We collected quantitative and qualitative data about 303 higher education teaching activities on psychosocial care in dementia across Europe. The analysis revealed that the number of teaching activities focusing on psychosocial care in dementia was relative. Although the results reflected UNESCO indications, the teaching activities on psychosocial care in dementia appeared less systematized than optimal. As world health agencies recommend, international higher education systems should consider more psychosocial care topics because they can prepare professionals to respond timely and effectively to dementia patients and caregivers' needs.

I-CARE-An Interaction System for the Individual Activation of People with Dementia

I-CARE is a hand-held activation system that allows professional and informal caregivers to cognitively and socially activate people with dementia in joint activation sessions without special training or expertise. I-CARE consists of an easy-to-use tablet application that presents activation content and a server-based backend system that securely manages the contents and events of activation sessions. It tracks various sources of explicit and implicit feedback from user interactions and different sensors to estimate which content is successful in activating individual users. Over the course of use, I-CARE's recommendation system learns about the individual needs and resources of its users and automatically personalizes the activation content. In addition, information about past sessions can be retrieved such that activations seamlessly build on previous sessions while eligible stakeholders are informed about the current state of care and daily form of their protegees. In addition, caregivers can connect with supervisors and professionals through the I-CARE remote calling feature, to get activation sessions tracked in real time via audio and video support. In this way, I-CARE provides technical support for a decentralized and spontaneous formation of ad hoc activation groups and fosters tight engagement of the social network and caring community. By these means, I-CARE promotes new care infrastructures in the community and the neighborhood as well as relieves professional and informal caregivers.

Music Connects Us: Development of a Music-Based Group Activity Intervention to Engage People Living with Dementia and Address Loneliness

There is a need for intervention research to understand how music-based group activities foster engagement in social interactions and relationship-building among care home residents living with moderate to severe dementia. The purpose of this conceptual paper is to describe the design of ‘Music Connects Us’, a music-based group activity intervention. Music Connects Us primarily aims to promote social connectedness and quality of life among care home residents living with moderate to severe dementia through engagement in music-making, supporting positive social interactions to develop intimate connections with others. To develop Music Connects Us, we adapted the ‘Music for Life’ program offered by Wigmore Hall in the United Kingdom, applying an intervention mapping framework and principles of engaged scholarship. This paper describes in detail the Music Connects Us program, our adaptation approach, and key adaptations made, which included: framing the project to focus on the engagement of the person living with dementia to ameliorate loneliness; inclusion of student and other community-based musicians; reduced requirements for care staff participation; and the development of a detailed musician training approach to prepare musicians to deliver the program in Canada. Description of the development, features, and rationale for Music Connects Us will support its replication in future research aimed to tests its effects and its use in clinical practice.

Music playlists for people with dementia: Qualitative evaluation of a guide for caregivers

This study aimed to evaluate a set of guidelines for music use with people with dementia. A secondary aim was to identify challenges and barriers to implementation of music interventions by caregivers. Caregivers (n = 16) were interviewed after implementing a music listening programme based on the guidelines with 29 people with dementia in home-care and aged care facilities. Caregivers found the guidelines informative, easy to understand and use. Positive effects on mood, reduced agitation and reduced challenges to care were reported. Difficulties with technology and finding time to implement the music programme were identified. Results highlight the need for more research around appropriate technology and the streamlining of processes and procedures for aged care staff. Further iterations of the guidelines will need to address these issues and consider the differing needs of home-based carers and aged care providers separately.

New musical interfaces for older adults in residential care: assessing a user-centred design approach

Purpose:For older adults in aged-care, group music-making can bring numerous physical and psychological benefits, ultimately improving their quality of life. However, personalising music-making to optimise these benefits is often difficult given their diverse ages, experiences, abilities, cognitive and motor skills, and their experience with music technology.Materialsandmethods:In this study, we conducted a 10-week group music-making intervention with twenty participants in an aged-care home, using a prototype digital musical instrument that we iteratively refined by following a user-centred design approach from direct resident feedback. The prototype instrument adopted a novel method for errorless learning in music-making settings, which we also refined, by increasing the difficulty level of the instrument's operation. We also assessed the residents' engagement with the sessions by obtaining feedback from caregivers and facilitators.Results:Results show that residents' enjoyment decreased as the complexity (difficulty) of our errorless learning implementation increased. We also found that resident engagement increased when changes to the prototype digital musical instrument were provided, but not when residents were giving feedback. Results also found that participation over the course of the intervention, and the number of songs played during each session also enhanced engagement.Conclusions: Overall, our results show the intervention was beneficial to residents, although we note some areas of enhancement for further interventions in designing prototype musical instruments for group music-making in aged-care settings. IMPLICATIONS FOR REHABILITATIONOlder adults positively engage with novel music technology, and do so increasingly over subsequent sessions. Repeated sessions may have the potential to enhance longer-term adoption of technologies as well as any rehabilitative effects of the group music-making activity.There is significant potential for residents with different abilities to all make music together, although to maximise the sustainability of the devices, the sessions, and the subsequent rehabilitative benefits, residents must be given the right adaptation for individual interfaces that balances ambition and ability.Rapid DMI prototyping positively enhances engagement among older adults, suggesting that in the case of a custom DMI, an upgrade schedule should be aligned with key rehabilitative milestones. Similarly, in the case of pre-developed digital music systems, resident exposure to new features or functionality should be strategically introduced, so as to maximise engagement for key phases of resident rehabilitation.

The Integration of Psychosocial Care into National Dementia Strategies across Europe: Evidence from the Skills in DEmentia Care (SiDECar) Project

There is evidence supporting the use of psychosocial interventions in dementia care. Due to the role of policy in clinical practice, the present study investigates whether and how the issue of psychosocial care and interventions has been addressed in the national dementia plans and strategies across Europe. A total of 26 national documents were found. They were analyzed by content analysis to identify the main pillars associated with the topic of psychosocial care and interventions. Specifically, three categories emerged: (1) Treatment, (2) Education, and (3) Research. The first one was further divided into three subcategories: (1) Person-centred conceptual framework, (2) Psychosocial interventions, and (3) Health and social services networks. Overall, the topic of psychosocial care and interventions has been addressed in all the country policies. However, the amount of information provided differs across the documents, with only the category of 'Treatment' covering all of them. Furthermore, on the basis of the existing policies, how the provision of psychosocial care and interventions would be enabled, and how it would be assessed are not fully apparent yet. Findings highlight the importance of policies based on a comprehensive and well-integrated system of care, where the issue of psychosocial care and interventions is fully embedded.

Quality indicators for community dementia care: a systematic review

BACKGROUND

There is a lack of an up-to-date body of evidence and a comprehensive overview concerning literature on quality indicator (QI) development for dementia care. Therefore, we systematically reviewed recent literature and formulated recommendations for future research.

METHODS

PubMed, CINAHL and The Cochrane Library were searched for studies describing QI development or redefinition for dementia care (from first symptoms until admission to long-term care), published from 2008 to May 2019.

RESULTS

We included a total of 7 articles, comprising of 107 QIs. The majority of publications originated from Europe. These applied to outpatient care, primary care and end-of-life care. Most QIs referred to care processes. Several care domains were determined by the authors, ranging from screening and assessment to end-of-life care. The methodological quality of the QI sets differed considerably. The QI sets with the best methodological quality were developed using expert evaluation or a Delphi technique.

CONCLUSIONS

It can be concluded that a reasonable amount of QIs for assessing and optimizing community dementia care exists, however, further development and methodological improvements of these QIs are necessary. Involvement of people with dementia and caregivers in the development process and a broader focus including community oriented next to medically oriented QIs are examples of potential improvement measures.

Preferred Music Listening Intervention in Nursing Home Residents with Cognitive Impairment: A Randomized Intervention Study

BACKGROUND

The current trend in addressing symptoms of dementia comprises non-pharmacological strategies such as music interventions for the management and improvement of cognitive function, memory, agitation, depression, or anxiety.

OBJECTIVE

To determine the impact of a preferred music listening group intervention upon the functional, cognitive, and emotional dimensions in nursing home residents.

METHODS

A randomized intervention study was carried out. The study was conducted from June to August 2015, and involved a preferred music listening group intervention lasting 60 minutes, 5 days/week during 8 weeks. A total of 119 adults aged ≥65 years, with annual permanent residence in the nursing home (Málaga, Spain) were included in the study. 47 (39.5%) subjects were randomized to the music group intervention. The nurses and physiotherapists were blinded to the assessments.

RESULTS

The sample had a mean age of 80.52 (SD7.44) years, with female predominance. The subjects presented dependency in Barthel, and cognitive impairment as determined by the MMSE. The Tinetti scores yielded fall risk and depression as evidenced by the Yesavage scale. The Cornell scores evidenced no depression in elderly people with dementia. Following the intervention, function improved significantly with a medium effect size, as did emotional state, with a large effect size. Cognitive function was seen to worsen in the control group, but remained stable in the intervention group, with a large effect size.

CONCLUSIONS

A preferred music listening group intervention among elderly people in nursing homes is effective, resulting in improvements in functional and emotional condition.

Nonpharmacological Strategies Used By Family Caregivers of Persons With Alzheimer's Disease and Related Dementias as Presented in Blogs

Individuals with Alzheimer's disease and related dementias (ADRD) may exhibit behavioral and psychological symptoms of dementia that can increase the strain experienced by their family caregivers. This strain correlates with increased stress and reduced quality of life for the family caregiver and individual with ADRD. More information is needed regarding the ways in which caregivers manage the caregiving experience in their efforts to reduce strain and maintain or improve quality of life. Many individuals, including dementia caregivers, use web blogs as online journals to share their lived experiences. The current study used blogs written by family caregivers of persons with ADRD to explore strategies used to support their care recipients. Using a qualitative thematic analysis, six themes related to the strategies used by caregivers were identified: Modifying the Physical and Personal Environment; Engaging the Person With ADRD; Seeking Outside Assistance; Using Complementary Therapies; Planning and Organization; and Reminiscing and Traditions. The current findings extend our understanding of strategies for caregiving that are used by and acceptable to family caregivers of persons with ADRD. This information can be used to develop or modify nursing-related interventions and services aimed at improving caregiver strain and quality of life. [Journal of Gerontological Nursing, 45(7), 25-35.].

A cluster-randomized crossover trial of Montessori activities delivered by family carers to nursing home residents with behavioral and psychological symptoms of dementia

OBJECTIVES

One-on-one structured Montessori-based activities conducted with people with dementia can improve agitation and enhance engagement. These activities may however not always be implemented by nursing home staff. Family members may present an untapped resource for enabling these activities. This study aimed to evaluate the impact of the Montessori activities implemented by family members on visitation experiences with people who have dementia.

DESIGN

Cluster-randomized crossover design.

SETTING

General and psychogeriatric nursing homes in the state of Victoria, Australia.

PARTICIPANTS

Forty participants (20 residents and 20 carers) were recruited.

INTERVENTION

During visits, family members interacted with their relative either through engaging in Montessori-based activities or reading a newspaper (the control condition) for four 30-minute sessions over 2 weeks.

MEASUREMENTS

Residents' predominant affect and engagement were rated for each 30-second interval using the Philadelphia Geriatric Center Affect Rating Scale and the Menorah Park Engagement Scale. The Pearlin Mastery Scale was used to rate carers satisfaction with visits. The 15-item Mutuality Scale measured the carers quality of their relationship with the resident. Carers' mood and overall quality of life were measured using the Center for Epidemiological Studies Depression Scale and Carer-QoL questionnaires, respectively.

RESULTS

Linear regressions within the generalized estimating equations approach assessed residents' and carers' outcomes. Relative to the control condition, the Montessori condition resulted in more positive engagement (b = 13.0, 95%CI 6.3-19.7, p < 0.001) and affect (b = 0.4, 95%CI 0.2-0.6, p < 0.001) for the residents and higher satisfaction with visits for carers (b = 1.7, 95%CI 0.45-3.00, p = 0.008). No correction was applied to p-values for multiple comparisons.

CONCLUSION

This study strengthens the evidence base for the use of the Montessori programs in increasing well-being in nursing home residents. The findings also provide evidence that family members are an additional valuable resource in implementing structured activities such as the Montessori program with residents.

Assessment of Cognitive Training & Social Interaction in People with Mild to Moderate Dementia: A Pilot Study

Objectives: To evaluate the cognitive, neuropsychiatric, and quality of life outcomes of computer-based cognitive training and social interaction on people with mild to moderate dementia. Methods: Ten individuals with dementia were recruited to complete a cognitive training regimen. They were randomly assigned to a high social interaction (HSI) group (n = 5) and low social interaction (LSI) group (n = 5). Eight of the original 10 participants completed the cognitive training and were evaluated on cognitive abilities, neuropsychiatric symptoms (NPS), and quality of life (QoL). Results: Mean scores for the HSI group increased on cognitive assessments, where mean scores for the LSI group saw decline, or stability. There was an overall reduction in the frequency and severity of NPS presentation in both the HSI and LSI group. Mixed results were found for mean changes in QoL. Discussion: These results support the idea of social interaction influencing cognitive outcomes, cognitive training influencing NPS, and both social interaction and cognitive training influencing QoL. The findings illustrate the feasibility and importance of incorporating social activity to computerized cognitive training for people with dementia. Clinical Implications: Cognitive training that incorporates social interaction may be a promising intervention for individuals with dementia experiencing NPS.

The Multidisciplinary Approach to Alzheimer's Disease and Dementia. A Narrative Review of Non-Pharmacological Treatment

Background: Alzheimer's disease (AD) and dementia are chronic diseases with progressive deterioration of cognition, function, and behavior leading to severe disability and death. The prevalence of AD and dementia is constantly increasing because of the progressive aging of the population. These conditions represent a considerable challenge to patients, their family and caregivers, and the health system, because of the considerable need for resources allocation. There is no disease modifying intervention for AD and dementia, and the symptomatic pharmacological treatments has limited efficacy and considerable side effects. Non-pharmacological treatment (NPT), which includes a wide range of approaches and techniques, may play a role in the treatment of AD and dementia. Aim: To review, with a narrative approach, current evidence on main NPTs for AD and dementia. Methods: PubMed and the Cochrane database of systematic reviews were searched for studies written in English and published from 2000 to 2018. The bibliography of the main articles was checked to detect other relevant papers. Results: The role of NPT has been largely explored in AD and dementia. The main NPT types, which were reviewed here, include exercise and motor rehabilitation, cognitive rehabilitation, NPT for behavioral and psychological symptoms of dementia, occupational therapy, psychological therapy, complementary and alternative medicine, and new technologies, including information and communication technologies, assistive technology and domotics, virtual reality, gaming, and telemedicine. We also summarized the role of NPT to address caregivers' burden. Conclusions: Although NPT is often applied in the multidisciplinary approach to AD and dementia, supporting evidence for their use is still preliminary. Some studies showed statistically significant effect of NPT on some outcomes, but their clinical significance is uncertain. Well-designed randomized controlled trials with innovative designs are needed to explore the efficacy of NPT in AD and dementia. Further studies are required to offer robust neurobiological grounds for the effect of NPT, and to examine its cost-efficacy profile in patients with dementia.

Quality indicators of psychotropic prescribing to people with dementia in aged psychiatry inpatient units

OBJECTIVES

To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia.

METHOD

The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and 'as needed' psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans.

RESULTS

The most problematic areas concerned the gathering of information about patients' psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services.

CONCLUSION

The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.

Longitudinal Effects of Activities, Social Environment, and Psychotropic Medication Use on Behavioral Symptoms of Individuals With Alzheimer's Disease in Nursing Homes

A secondary data analysis of 25,560 minutes of structured clinical observations from a longitudinal study examined the impact of time-varying background factors, social environment, and psychotropic medication use on behavioral symptoms of nursing home residents with Alzheimer's disease (AD). Data were collected at baseline (N = 177), 12 months (N = 138), and 24 months (N = 111). Mixed-effects regression modeling showed that at 24 months: (a) higher cognitive and physical function and having a private bedroom/bathroom had the most positive influence on resident positive behaviors; (b) use of antipsychotic medications and solitary activities had the most negative influence on resident positive behaviors; (c) higher cognitive function significantly decreased negative behaviors; and (d) care-related activities and total number of psychotropic medications significantly increased negative behaviors. The current study describes risk factors for behavioral disturbances and the impact of activities, social environment, and psychotropic medications on behavioral outcomes in nursing home residents with AD. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 18-26.].

Systematic review of the impact of arts for health activities on health, wellbeing and quality of life of older people living in care homes

Care home populations frequently feature older people who often experience poor physical health and cognitive difficulties, along with vulnerability to psychological and social stressors. To date there has been no systematic review which focuses on the impact of arts for health activities to the care home population. Evidence was sourced from several databases and 71 studies were deemed eligible for inclusion in this review. These studies underwent data extraction and quality appraisal and the findings associated with health, wellbeing and quality of life are presented within this paper.

Challenges faced and lessons learned A multi-component prospective memory training program for Malaysian older adults

The surrounding circumstances and environments of Malaysian older adults could make conducting interventions (mainly in terms of clinical or randomized controlled trials) a challenge. Working with older adults and facing cultural issues could be challenging.

The use of music in aged care facilities: A mixed-methods study

Music is frequently used in aged care, being easily accessible and cost-effective. Research indicates that certain types of musical engagement hold greater benefits than others. However, it is not clear how effectively music is utilized in aged care facilities and what the barriers are to its further use. This study used a mixed-methods paradigm, surveying 46 aged care workers and conducting in-depth interviews with 5, to explore how music is used in aged care facilities in Australia, staff perceptions of the impact of music on residents, and the barriers to more effective implementation of music in aged care settings.

Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia

Background and Objectives

To draw from systematic and other literature reviews to identify, describe, and critique nonpharmacological practices to address behavioral and psychological symptoms of dementia (BPSDs) and provide evidence-based recommendations for dementia care especially useful for potential adopters.

Research Design and Methods

A search of systematic and other literature reviews published from January 2010 through January 2017. Nonpharmacological practices were summarized to describe the overall conceptual basis related to effectiveness, the practice itself, and the size and main conclusions of the evidence base. Each practice was also critically reviewed to determine acceptability, harmful effects, elements of effectiveness, and level of investment required, based on time needed for training/implementation, specialized care provider requirements, and equipment/capital requirements.

Results

Nonpharmacological practices to address BPSDs include sensory practices (aromatherapy, massage, multi-sensory stimulation, bright light therapy), psychosocial practices (validation therapy, reminiscence therapy, music therapy, pet therapy, meaningful activities), and structured care protocols (bathing, mouth care). Most practices are acceptable, have no harmful effects, and require minimal to moderate investment.

Discussion and Implications

Nonpharmacological practices are person-centered, and their selection can be informed by considering the cause and meaning of the individual's behavioral and psychological symptoms. Family caregivers and paid care providers can implement evidence-based practices in home or residential care settings, although some practices require the development of more specific protocols if they are to become widely used in an efficacious manner.

Effectiveness of Environment-Based Interventions That Address Behavior, Perception, and Falls in People With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE

This systematic review evaluated the effectiveness of environment-based interventions that address behavior, perception, and falls in the home and other settings for people with Alzheimer's disease (AD) and related major neurocognitive disorders (NCDs).

METHOD

Database searches were limited to outcomes studies published in English in peer-reviewed journals between January 2006 and April 2014.

RESULTS

A total of 1,854 articles were initially identified, of which 42 met inclusion criteria.

CONCLUSION

Strong evidence indicates that person-centered approaches can improve behavior. Moderate evidence supports noise regulation, environmental design, unobtrusive visual barriers, and environmental relocation strategies to reduce problematic behaviors. Evidence is insufficient for the effectiveness of mealtime ambient music, bright light, proprioceptive input, wander gardens, optical strategies, and sensory devices in improving behavior or reducing wandering and falls. Although evidence supports many environment-based interventions used by occupational therapy practitioners to address behavior, perception, and falls in people with AD and related major NCDs, more studies are needed.

Effect of wearing fingers rings on the behavioral and psychological symptoms of dementia: An exploratory study

Objective:

This study was conducted to examine the effects of an approach that wears finger rings on elderly females with behavioral and psychological symptoms of dementia.

Method:

The subjects were seven Japanese dementia patients living in elderly nursing homes. A single-case experimental design was adopted for the study. Each study subject was asked to put rings on her finger (from 9:00 to 19:00) for 7 days. The Neuropsychiatric Inventory, scenes of behavioral and psychological symptoms of dementia, interest in wearing rings, self-awareness, and overall profile were determined to assess the effect on the patients of wearing rings.

Results:

The majority of nursing care providers stated, based on their assessment, that the “irritability/lability” that was noted during the baseline period disappeared during the ring-wearing intervention period in the three patients who displayed an interest in rings. In the assessment of the self-awareness ability, these three women were aware themselves of their intellect collapsing and were capable of conjecturing their own and others’ minds. It was commonly seen that the nursing staff, even though they had not been asked to do so by the researchers, told the patients, “Mrs. XX, you look so beautiful” when they found a patient wearing rings.

Discussion/conclusion:

Individuals with low self-esteem are inclined to get angry and display aggression. In subjects with low self-esteem, anger and aggression readily arise when they are slighted by others. Self-esteem is low in those women who are aware of their own status of collapsing intellect. It is concluded that the words of conjuration, “you look so beautiful,” which the wearing of the ring per se by the patient elicited from the caregivers heightened the self-esteem and alleviated “irritability/lability” in the study subjects.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background

Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.

Objectives

To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.

Review methods

Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.

Design

ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.

Settings

ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.

Participants

ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.

Intervention

An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.

Main outcome measures

ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.

Results

ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.

Limitations

Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.

Conclusions

A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.

Future work

There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.

Trial registration

Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review

BACKGROUND

Poor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents' responsive behaviors to oral care and residents' lack of ability or motivation to perform oral care on their own.

OBJECTIVES

To evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents' responsive behaviors to oral care, or enable/motivate residents to perform their own oral care.

MATERIALS AND METHODS

We searched the databases Medline, EMBASE, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results.

RESULTS

We included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems.

CONCLUSIONS

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents' responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

A pilot study using "apps" as a novel strategy for the management of challenging behaviors seen in people living in residential care

BACKGROUND

Many adults living in residential care will demonstrate challenging behaviors. Non-pharmacological strategies are recommended as first-line treatment. Using applications (apps) is a novel approach to managing these behaviors, and has yet to be assessed in this group. This paper describes a pilot study to test apps as a novel non-pharmacological strategy to manage challenging behaviors in adults living in residential care.

METHODS

A non-blinded, non-randomized crossover trial design was implemented which compared apps to a control situation and usual care to determine whether apps were able to decrease challenging behaviors. The primary outcome measure was the Neuropsychiatric Inventory (NPI) that measures the frequency and severity of these behaviors.

RESULTS

Fifteen residents participated whose mean age was 78.5 years. There were a range of diagnoses and comorbidities, including dementia and schizophrenia. IPads were used as the medium for delivering the apps and residential care staff implemented the interventions. There was a significant decrease in the total NPI score using the apps intervention (10.6 points) compared to the control (17.7 points) and to usual care (21.1 points). There was positive qualitative feedback from the staff who were involved in the study, but they also cited barriers such as lack of confidence using the apps and lack of time.

CONCLUSIONS

Although this was a small and limited study, results suggest that using apps may be a feasible and personalized approach to managing challenging behaviors. A more rigorous study design that includes larger sample sizes and staff training may enable further research and benefits in this area.

Psychosocial Intervention Use in Long-Stay Dementia Care: A Classic Grounded Theory

The objective of this study was to develop a substantive grounded theory of staff psychosocial intervention use with residents with dementia in long-stay care. "Becoming a person again" emerged as the core category accounting for staffs' psychosocial intervention use within long-stay care. Interview data were collected from participants in nine Irish long-stay settings: 14 residents with dementia, 19 staff nurses, one clinical facilitator, seven nurse managers, 21 nursing assistants, and five relatives. Constant comparative method guided the data collection and analysis. The researcher's theoretical memos, based on unstructured observation, and applicable extant literature were also included as data. By identifying the mutuality of the participants' experiences, this classic grounded theory explains staff motivation toward psychosocial intervention use within long-stay care. It also explains how institutional factors interact with those personal factors that incline individuals toward psychosocial intervention use.

Pilot Testing of the EIT-4-BPSD Intervention

Behavioral and psychological symptoms of dementia are common in nursing home residents, and the Centers for Medicare and Medicaid Services now require that nonpharmacological interventions be used as a first-line treatment. Few staff know how to implement these interventions. The purpose of this study was to pilot test an implementation strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD), which was developed to help staff integrate behavioral interventions into routine care. The EIT-4-BPSD was implemented in 2 nursing homes, and 21 residents were recruited. A research nurse facilitator worked with facility champions and a stakeholder team to implement the 4 steps of EIT-4-BPSD. There was evidence of reach to all staff; effectiveness with improvement in residents' quality of life and a decrease in agitation; adoption based on the environment, policy, and care plan changes; and implementation and plans for maintenance beyond the 6-month intervention period.

Better self-management and meaningful activities thanks to tablets? Development of a person-centered program to support people with mild dementia and their carers through use of hand-held touch screen devices

BACKGROUND

To offer good support to people with dementia and their carers in an aging and Internet society the deployment of hand-held touch screen devices, better known as tablets, and its applications (apps) can be viable and desirable. However, at the moment it is not clear which apps are usable for supporting people with dementia in daily life. Also, little is known about how people with dementia can be coached to learn to use a tablet and its apps.

METHODS

A person-centered program, with tools and training, will be developed that aims to support people with mild dementia and their (in)formal carers in how to use the tablet for self-management and meaningful activities. The program will be developed in accordance with the Medical Research Council's (MRC) framework for developing and evaluating complex interventions and the study will cover the following phases: a preclinical or theoretical (0) phase; a modeling phase (I) and the exploratory trial phase (II). The users (people with dementia and their carers) will be involved intensively during all these phases, by means of individual interviews, workshops, focus groups, and case studies.

DISCUSSION

The iterative process inherent to this framework makes it possible to develop a user-oriented intervention, in this case a person-centered program, for the use of tablets in dementia care. Preparatory work will be done to perform a methodologically sound randomized controlled trial (RCT) in the near future, which aims to investigate the contribution of this person-centered program for tablet use to the quality of life of people with dementia and their carers.

Behavioral emergency in the elderly: a descriptive study of patients referred to an Aggression Response Team in an acute hospital

Aim

The management of severely agitated elderly patients is not easy, and limited guidelines are available to assist practitioners. At a Sydney hospital, an Aggression Response Team (ART) comprising clinical and security staff can be alerted when a staff member has safety concerns. Our aims were to describe the patient population referred for ART calls, reasons for and interventions during ART calls, and complications following them.

Methods

Patients 65 years and older referred for ART calls in the emergency department or wards during 2014 were identified using the Incident Information Management System database and medical records were reviewed. Demographic and clinical data were collected.

Results

Of 43 elderly patients with ART calls, 30 had repeat ART calls. Thirty-one patients (72%) had underlying dementia, and 22 (51%) were agitated at the time of admission. The main reasons for ART calls were wandering and physical aggression. Pharmacological sedation was used in 88% of the ART calls, with a range of psychotropics, doses, and routes of administration, including intravenous (19%) and, most commonly, midazolam (53%). Complications were documented in 14% of cases where sedation was used.

Conclusion

We observed a high frequency of pharmacological sedation among the severely agitated elderly, with significant variance in the choice and dose of sedation and a high rate of complications arising from sedation, which may be an underestimate given the lack of post-sedation monitoring. We recommend the development of guidelines on the management of behavioral emergency in the elderly patients, including de-escalation strategies and standardized psychotropic guidelines.

Psychosocial interventions for people with dementia: An overview and commentary on recent developments

An influential review in 2010 concluded that non-pharmacological multi-component interventions have positive effects on cognitive functioning, activities of daily living, behaviour and mood of people with dementia. Our aim here is to provide an up-to-date overview of research into psychosocial interventions and their impact on psychosocial outcomes. We focused on randomised controlled trials, controlled studies and reviews published between October 2008 and August 2015, since the earlier review. The search of PsychInfo, Medline and the Cochrane database of systematic reviews yielded 61 relevant articles, organised into four themes echoing key phases of the care pathway: Living at home with dementia (five reviews, eight studies), carer interventions (three reviews, four studies), interventions in residential care (16 reviews, 12 studies) and end-of-life care (three reviews, two studies), along with an additional group spanning community and institutional settings (six reviews, two studies). Community findings suggested that appointment of dementia specialists and attention to case management can produce positive outcomes; physical therapies, cognitive training and modified cognitive behaviour therapy also had a range of benefits. There was more limited evidence of positive benefits for people with dementia through interventions with family carers. Thirty-two articles focused on the management of 'behavioural symptoms' through a range of interventions all of which had some evidence of benefit. Also a range of multi-component and specific interventions had benefits for cognitive, emotional and behavioural well-being of people with dementia in residential settings, as well as for quality of life. Overall, interventions tended to be short term with impact only measured in the short term. We recommend further research on interventions to promote living well in the community post-diagnosis and to address end-of-life care. Development of psychosocial interventions would benefit from moving beyond the focus on control of behaviours to focus on wider aspects of life for people with dementia.

Understanding the world of dementia. How do people with dementia experience the world?

BACKGROUND

There is growing awareness that the subjective experience of people with dementia is important for understanding behavior and improving quality of life. This paper reviews and reflects on the currently available theories on subjective experience in dementia and it explores the possibility of a knowledge gap on the influence of neurological deficits on experience in late stage dementia.

METHODS

A literature review on current commonly used theories on experience in dementia was supplemented with a systematic review in PubMed and Psychinfo. For the systematic review, the terms used were Perception and Dementia and Behavior; and Awareness and Dementia and Long term care.

RESULTS

Current models emphasize the psychosocial factors that influence subjective experience, but the consequences of neurological deficits are not elaborated upon. The systematic literature search on the neuropsychological functioning in dementia resulted in 631 papers, of which 94 were selected for review. The current knowledge is limited to the early stages of Alzheimer's disease. Next to memory impairments, perception of the direct environment, interpretation of the environment, and inhibition of own responses to the environment seem to be altered in people with dementia.

CONCLUSIONS

Without knowledge on how perception, interpretation and the ability for response control are altered, the behavior of people with dementia can easily be misinterpreted. Research into neuropsychological functioning of people in more severe stages and different forms of dementia is needed to be able to develop a model that is truly biopsychosocial. The proposed model can be used in such research as a starting point for developing tests and theories.

Multisensory Stimulation as an Intervention Strategy for Elderly Patients With Severe Dementia: A Pilot Randomized Controlled Trial

The objective of this study was to compare the effect of multisensory stimulation environment (MSSE) and one-to-one activity sessions in the symptomatology of elderly individuals with severe dementia. Thirty-two participants were randomly assigned to the following 3 groups: MSSE, activity, and control group. The MSSE and activity groups participated in two 30-minute weekly sessions over 16 weeks. Pre-, mid-, and posttrial; 8-week follow-up behavior; mood; cognitive status; and dementia severity were registered. Patients in the MSSE group demonstrated a significant improvement in the Neuropsychiatric Inventory and Bedford Alzheimer Nursing Severity Scale scores compared with the activity group. Both MSSE and activity groups showed an improvement during the intervention in the Cohen-Mansfield Agitation Inventory aggressive behavior factor and total score, with no significant differences between groups. The MSSE may have better effects on neuropsychiatric symptoms and dementia severity in comparison with one-to-one activity sessions in patients with severe dementia.

A meta-review of stress, coping and interventions in dementia and dementia caregiving

Background

There has been a substantial number of systematic reviews of stress, coping and interventions for people with dementia and their caregivers. This paper provides a meta-review of this literature 1988-2014.

Method

A meta-review was carried out of systematic reviews of stress, coping and interventions for people with dementia and their caregivers, using SCOPUS, Google Scholar and CINAHL Plus databases and manual searches.

Results

The meta-review identified 45 systematic reviews, of which 15 were meta-analyses. Thirty one reviews addressed the effects of interventions and 14 addressed the results of correlational studies of factors associated with stress and coping. Of the 31 systematic reviews dealing with intervention studies, 22 focused on caregivers, 6 focused on people with dementia and 3 addressed both groups. Overall, benefits in terms of psychological measures of mental health and depression were generally found for the use of problem focused coping strategies and acceptance and social-emotional support coping strategies. Poor outcomes were associated with wishful thinking, denial, and avoidance coping strategies. The interventions addressed in the systematic reviews were extremely varied and encompassed Psychosocial, Psychoeducational, Technical, Therapy, Support Groups and Multicomponent interventions. Specific outcome measures used in the primary sources covered by the systematic reviews were also extremely varied but could be grouped into three dimensions, viz., a broad dimension of “Psychological Well-Being v. Psychological Morbidity” and two narrower dimensions of “Knowledge and Coping” and of “Institutionalisation Delay”.

Conclusions

This meta-review supports the conclusion that being a caregiver for people with dementia is associated with psychological stress and physical ill-health. Benefits in terms of mental health and depression were generally found for caregiver coping strategies involving problem focus, acceptance and social-emotional support. Negative outcomes for caregivers were associated with wishful thinking, denial and avoidance coping strategies. Psychosocial and Psychoeducational interventions were beneficial for caregivers and for people with dementia. Support groups, Multicomponent interventions and Joint Engagements by both caregivers and people with dementia were generally found to be beneficial. It was notable that virtually all reviews addressed very general coping strategies for stress broadly considered, rather than in terms of specific remedies for specific sources of stress. Investigation of specific stressors and remedies would seem to be a useful area for future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0280-8) contains supplementary material, which is available to authorized users.

Effective strategies to motivate nursing home residents in oral healthcare and to prevent or reduce responsive behaviours to oral healthcare: a systematic review protocol

INTRODUCTION

Oral healthcare in nursing homes is less than optimal, with severe consequences for residents' health and quality of life. To provide the best possible oral healthcare to nursing home residents, care providers need strategies that have been proven to be effective. Strategies can either encourage and motivate residents to perform oral healthcare themselves or can prevent or overcome responsive behaviours from residents when care providers assist with oral healthcare. This systematic review aims to identify studies that evaluate the effectiveness of such strategies and to synthesise their evidence.

METHODS AND ANALYSIS

We will conduct a comprehensive search in the databases MEDLINE, EMBASE, Evidence Based Reviews--Cochrane Central Register of Controlled Trials, CINAHL and Web of Science for quantitative intervention studies that assess the effectiveness of eligible strategies. 2 reviewers will independently screen titles, abstracts and retrieved full texts for eligibility. In addition, contents of key journals, publications of key authors and reference lists of all studies included will be searched by hand and screened by 2 reviewers. Discrepancies at any stage of the review process will be resolved by consensus. Data extraction will be performed by 1 research team member and checked by a second team member. 2 reviewers will independently assess methodological quality of studies included using 3 validated checklists appropriate for different research designs. We will present a narrative synthesis of study results.

ETHICS AND DISSEMINATION

We did not seek ethics approval for this study, as we will not collect primary data and data from studies included cannot be linked to individuals or organisations. We will publish findings of this review in a peer-reviewed paper and present them at an international peer-reviewed conference.

TRIAL REGISTRATION NUMBER

CRD42015026439.