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

Factors Influencing the Implementation of Non-Pharmacological Interventions for Behavioural and Psychological Symptoms of Dementia in Residential Aged-Care Homes: A Systematic Review and Qualitative Evidence Synthesis: A systematic review

Background

Non-pharmacological interventions (NPIs) are the primary approaches to the management of behavioural and psychological symptoms of dementia (BPSD), but studies have indicated that there is a suboptimal implementation. Although there are several studies on the factors influencing NPI implementation for BPSD at residential aged-care homes (RACHs), there has not been a comprehensive qualitative systematic review on the topic.

Objectives

This systematic review aimed to examine the qualitative studies that investigate the factors influencing the implementation of NPIs for managing BPSD in RACHs.

Search Methods

Systematic searches were conducted up until 31 December 2023 using five databases: MEDLINE, EMCARE, EMBASE, CINAHL complete and APA PsycINFO.

Selection Criteria

This systematic review included qualitative studies and qualitative data from mixed-method studies on the implementation of NPIs for RACH residents with dementia experiencing BPSD. The research question and inclusion criteria for this review included the components of PICo: Population (aged-care residents with dementia), Phenomenon of interest (factors influencing implementation of NPIs) and Context/setting (RACHs).

Data Collection and Analysis

After screening and extracting the data, the methodological limitations were assessed using the Joanna Briggs Institute System for the Unified Management, Assessment, and Review of Information (JBI SUMARI) quality assessment tool. JBI SUMARI meta-aggregative synthesis was used to synthesise the data. The extracted findings were categorised into the 10 Theoretical Domain Framework domains: knowledge, skills, environmental context and resources, social influences, reinforcement, emotions, intentions, beliefs about consequences, social and professional roles and beliefs about capability. Confidence in the output of qualitative research synthesis (CONQual) was used to assess the credibility and dependability of the synthesised findings.

Main Results

Twenty-four studies were included, from which factors influencing NPI implementation were extracted. Study participants included RACH managers, RACH care staff, families of aged-care residents with dementia and volunteers. Amongst the studies specifying the gender of participants, there were 352 females (84.4%) and 46 males (15.6%). The method of data collection for the included studies consisted of eighteen interviews, five focus group discussions and one qualitative survey. All except one study had a quality assessment score of at least 60% based on the JBI SUMARI quality assessment tool. However, all studies were included regardless of the result of the quality assessment result. These studies spanned the period from 2010 to 2022 and were mostly conducted in the United Kingdom, Australia, the United States and Canada. Twenty-four synthesised findings were identified (13 high, 7 moderate and 4 low ConQual scores). Examples of factors influencing the implementation of NPIs were collaboration amongst care staff and families of residents with dementia, belief in the efficacy of interventions, staffing, staff time constraints, funding, familiarity with the interventions, organisational support, communication amongst the care staff and with families of residents with dementia, education and training for the care staff and families of residents with dementia and familiarity with the residents with dementia.

Authors' Conclusions

This systematic review highlights and synthesises factors influencing the implementation of NPIs for managing BPSD in RACHs. Key factors include collaboration amongst staff and families, organisational support, staffing, education and staff familiarity with both the interventions and residents. Strengthening these areas could enhance the care outcomes for aged-care residents with dementia. For decision-makers, these insights suggest the need for comprehensive strategies to improve NPI implementation. This could include ensuring appropriate staffing levels, enhancing collaboration, allocating adequate funds, providing training, strengthening organisational support and improving the quality of information exchange amongst care staff, between care staff and volunteers and families of residents with dementia. For researchers, the findings from this systematic review could provide valuable insights including the need to explore strategies to overcome barriers to NPI implementation, especially investigating innovative models for staffing and collaborative practice, examining the effectiveness of different education and training approaches, and exploring organisational policies and support mechanisms that can enhance the implementation of NPIs.

Mixed methods feasibility study of Music Attuned Technology Care via eHealth (MATCH) for people with complex behavioral and psychological symptoms of dementia within an acute psychogeriatric ward

INTRODUCTION

Music-based strategies can reduce distress, agitation, and promote wellbeing in people with dementia. Research in specialized dementia care units is limited.

METHODS

Mixed-methods pre-post study evaluated the feasibility and preliminary effects of Music Attuned Technology Care via eHealth (MATCH) in a dementia-specialized inpatient ward. Staff completed MATCH training and administered MATCH strategies over 8 weeks with enrolled patients.

RESULTS

Twenty-four staff and 14 patients were recruited. Severity of dementia symptoms, measured by the Neuropsychiatric Inventory Questionnaire, was reduced (median change: -3.0, 95% CI: -9.5, 0.5), especially agitation (median change -3.0, 95% confidence interval -5.5, -0.5). Staff reported high acceptability of MATCH (median score: 13 [interquartile range: 12-14]) and implementing strategies enhanced person-centered care. Patients' positive responses to music motivated increased use. No changes in staff knowledge or patient depression were found.

DISCUSSION

MATCH was acceptable to staff and showed potential to reduce agitation symptoms and medication use, warranting further trials to determine effectiveness.

CLINICAL TRIAL REGISTRATION

The clinical trial is registered with the Australia New Zealand Clinical Trials Registry (ACTRN12623001134617).

HIGHLIGHTS

MATCH decreased the severity of dementia symptoms, measured by the NPI-Q. Staff reported high acceptability of MATCH. Personalized music enhanced person-centered care. Patients' positive responses to music motivated increased use. No changes in staff knowledge or patient depression were found.

HCA PIECESTM Care Coach Program: Peer-to-peer approach to promote person-centred care in long-term care

In Long-Term Care (LTC) settings, the potentially inappropriate use of antipsychotics for behavioural and psychological symptoms of dementia is a persistent issue, with high rates despite limited benefit and serious risk. Best practice is a non-pharmacological, person-centred approach to care, though this can be challenging in LTC settings. To help address this gap, we developed the PIECESTM HCA Care Coach Program and described its implementation and outcomes observed at 13 LTC homes. This program empowers healthcare aides with training, tools, and processes to practice the principles of person-centred care and provide peer mentorship to the care team. After one year, we found declining antipsychotics use (by 4.4%) and positive indicators of improved staff experience and improved resident quality of life. The Care Coach Program can be adapted and spread to a variety of LTC settings to help reduce potentially inappropriate antipsychotic use and better support people living with dementia.

A bibliometric study for global hotspots and trends in animal-assisted interventions (1983-2023)

Background

As a therapeutic approach, Animal-Assisted Intervention (AAI) has gained increasing recognition for enhancing both psychological and physical health. However, bibliometric studies in this field remain scarce.

Methods

This study aims to analyze AAI-related research from 1983 to 2023 using bibliometric methods. It examines sources of literature, core journals, highly cited documents, country and institutional distribution, prolific authors, and high-frequency keywords while tracking the evolution of research themes in AAI. A thematic search using the Boolean operator "OR" and AAI-related keywords in the Web of Science database yielded 405 articles, and data mining and visualization of these results were performed.

Results

The findings reveal a substantial increase in the number of published articles and citations over the past decade, indicating a rising research interest in this field. The United States and Purdue University have played a leading role in this area. Currently, AAI research is shifting from basic studies to intervention strategies targeting specific populations and diseases. Future research trends may include enhanced international collaboration, standardization of research methods, and the development of more targeted interventions.

Conclusion

These findings provide researchers, funding agencies, and policymakers with scientific insights and recommendations for future research directions in AAI.

Effective for Whom? A Review of Psychological and Social Intervention Recommendations in European Dementia Care Guidelines Through the Lenses of Social Health and Intersectionality

In dementia care, access to effective psychosocial interventions is often addressed by evidence-based guidelines for care providers. However, it is unclear if current guidelines consider personal characteristics that may impact intervention effectiveness. This study investigates if, and within what framing, dementia care guidelines in Europe address what is effective and for whom. A review of 47 guidelines from 12 European countries was conducted. Content analysis focused on (i) if guidelines recommended specific psychosocial interventions, and how guidelines referred to (ii) social health, (iii) the intersection of social positioning, and (iv) inequities in care or outcomes. Thirty-five guidelines (74%) recommended specific psychosocial interventions. Around half referenced aspects of social health and of intersectionality. Thirteen guidelines (28%) referenced inequities. Social health was not explicitly recognised as a mechanism of psychosocial interventions. Only age and comorbidity were consistently considered to impact interventions' effectiveness. Inequities were acknowledged to arise from within-country regional variations and individual economic status, but were not linked to (intersectional) individual societal positions such as sex and/or gender, sexuality, and/or religion. The results between European countries were heterogeneous. Current guidelines offer little insight into what works for whom. Policymakers and guideline developers should work with researchers, generating and translating evidence into policy.

Effectiveness of a Dyadic Technology-Enhanced Home-Based Horticultural Therapy on Psychosocial Well-Being Among People With Dementia and Their Family Caregivers: Multimethods Pilot Study

BACKGROUND

Horticultural therapy (HT) has been proposed to be an effective intervention for improving the psychosocial well-being of people with dementia and their caregivers. However, constraints such as limited land space in high-density cities, unstable weather, and lack of gardening experience may hamper the delivery of HT to people with dementia and their caregivers.

OBJECTIVE

This pilot study aimed to examine the feasibility and preliminary effects of a technology-enhanced home-based HT for people with dementia and their caregivers using a hydroponic indoor growing system.

METHODS

A single-group pre-post design was adopted. A total of 37 dyads of people with dementia and their caregivers participated in 3 weekly face-to-face sessions, followed by 8 weeks of home-based horticultural activities. Outcomes were measured at baseline and postintervention (at week 11), including feasibility outcomes, cognitive function, neuropsychiatric symptoms, and happiness levels of people with dementia. Caregivers' outcomes included positive aspects of caregiving, perceived stress levels, depressive symptoms, caregiver distress, and happiness levels. Semistructured focus group interviews were conducted with the caregivers to further explore their horticultural experience.

RESULTS

Intervention feasibility was established with a completion rate of 83.78% and an attrition rate of 2.63% (n=1). Significant improvements were detected in caregiver distress (P<.05) and the happiness level of people with dementia (P<.01). The qualitative findings indicated that HT improved the psychological well-being of both people with dementia and caregivers, enhanced the relationships between caregivers and people with dementia, expanded the caregivers' social networks, and enhanced the autobiographical memory of people with dementia.

CONCLUSIONS

This pilot study provides evidence on the feasibility of using a hydroponic indoor grower to conduct home-based HT for people with dementia and their caregivers. The findings suggest positive effects on the psychological well-being of both people with dementia and their caregivers. Caregivers reported potential positive effects of HT on the autobiographical memory retrieval of people with dementia. Due to the pilot nature of this study, a control group was not employed. Therefore, large-scale randomized controlled trials are encouraged to further confirm the effectiveness of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05577975; https://clinicaltrials.gov/study/NCT05577975.

Efficacy of music-based intervention for people living with dementia in an inpatient setting: A pilot study

BACKGROUND

Pharmacological treatment of behavioral and psychological symptoms of dementia is of limited benefit. The addition of non-pharmacological interventions is often essential for optimal symptom control. Music is a viable way to help patients communicate and improve their quality of life.

OBJECTIVE

This study aims to find the most effective way to use music in a busy dementia ward.

METHODS

17 inpatients (aged 63-93 years) with a clinical diagnosis of Alzheimer's disease and dementia took part over five weeks. Music lyrics presented via free-field speakers were individualized to personal preferences. Instruments (e.g., maracas) were used in some group sessions. We used the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Music in Dementia Assessment Scales (MiDAS) to evaluate patients' behavior before and after musical intervention.

RESULTS

There was a significant difference in mean NPI-Q scores before and after the music intervention. Specifically, Delusion, Motor Disturbances, and Agitation scores were significantly reduced after music intervention. This was accompanied by significant improvements in Interest, Response, and Enjoyment of MiDAS items during specific intervals.

CONCLUSIONS

Clinical professionals can successfully deliver music-based intervention to inpatients with advanced dementia to help manage their behavioral symptoms in the short term. Music-based interventions' use for inpatient wards must be further investigated as an economical and personalized non-pharmacological therapeutic tool for patients with dementia.

Multisensory Stimulation in Rehabilitation of Dementia: A Systematic Review

Background/Objectives: Dementia leads to cognitive decline, affecting memory, reasoning, and daily activities, often requiring full-time care. Multisensory stimulation (MSS), combined with cognitive tasks, can slow this decline, improving mood, communication, and overall quality of life. This systematic review aims to explore methods that utilize MSS in the rehabilitation of patients with dementia. Its clinical value is rooted in its ability to offer a deep comprehension of how MSS can be successfully incorporated into rehabilitation treatments. Methods: Studies were identified from an online search of PubMed, EBSCOhost, Cochrane Library, Web of Science, Embase, and Scopus databases with a search time frame from 2014 to 2024. This review has been registered on Open OSF (n) 3KUQX. Results: Pilot studies investigating MSS interventions, encompassing Cognitive Stimulation Therapy (CST), Sonas therapy, and combined physical-cognitive exercise programs, have yielded mixed findings in individuals with dementia. CST has demonstrated significant improvements in general cognitive function, particularly in language skills, offering a promising approach for cognitive enhancement. Sonas therapy, while showing positive trends in some studies, does not consistently achieve statistically significant outcomes across all cognitive domains. Conversely, combined exercise programs have shown efficacy in improving dual-task performance, suggesting benefits for motor-cognitive integration. MSS delivered within specialized environments like Snoezelen rooms consistently produces positive effects on mood, reducing agitation and promoting relaxation. Conclusions: This review emphasizes how MSS can enhance cognitive, emotional, and behavioral results for individuals with dementia. It is essential for future research to standardize protocols, incorporate advanced technologies such as virtual reality, and rectify diversity gaps. Collaboration between different fields will improve the effectiveness and usefulness of MSS in caring for individuals with dementia.

Impacts of adapted dance on mood and physical function among persons living with Alzheimer's disease

BACKGROUND

Most individuals living with Alzheimer's disease and related dementias (ADRD) experience one or more neuropsychiatric symptoms, such as agitation which negatively impacts their quality of life. Adapted dance integrates recorded music and movement that is appropriate for people with cognitive limitations. Adapted dance may be an enjoyable activity for persons living with ADRD and may provide psychological and physical benefits.

OBJECTIVE

The purpose of this pilot study was to assess the feasibility of an adapted dance intervention with persons with ADRD and the impacts of 12 weeks of adapted dancing on agitation, balance, gait, lower extremity strength, and caregiver burden.

METHODS

This study used an experimental design with repeated measures. Participants with ADRD were randomly assigned to a usual care or adapted line dance group that met 60 min twice a week. At pre-test, 4-, 8-, and 12 weeks of intervention, measures were collected for agitation, balance, gait, lower extremity strength, and caregiver burden.

RESULTS

The sample consisted of 4 males and 12 females (n = 16) with ADRD whose age ranged from 69-97 years. Twelve weeks of adapted line dance was found acceptable by ADRD participants. Participants attended ≥90% of dance sessions and did not experience loss of balance or fall. ADRD participants danced an average of 70 min per week. Both groups had improvements in agitation from baseline to 12 weeks.

CONCLUSIONS

Twelve weeks of adapted dance was shown to be feasible and enjoyable for persons living with ADRD. Clinicians should consider adapted dance as part of an exercise prescription.

Perceived health and working life in caregivers from nursing homes that used or did not use nighttime personalized non-pharmacological therapies to address residents' behavioral and psychological symptoms of dementia

Dementia is frequent in nursing home (NH), affecting between 40 and 50 % of the residents and is associated in 90 % of the cases with behavioral and psychological symptoms (BPSD) which are detrimental to caregivers' working life and perceived health. We compared perceived health and working life between NHs that used or did not use nighttime personalized non-pharmacological therapies (PNPT) to address BPSD. This anonymous survey included 96 caregivers from 25 NHs which used (n = 69) or not (n = 27) nighttime PNPT. Perceived health, nursing and medical care, quality of care and internal motivation were significantly higher, stress symptoms and workload were significantly lower and there was a tendency to enhanced satisfaction with work in caregivers from NHs which used nighttime PNPT. Our present data open a new window on the benefits of PNPT.

Effect of a Group-Based Personal Assistive RObot (PARO) Robot Intervention on Cognitive Function, Autonomic Nervous System Function, and Mental Well-being in Older Adults with Mild Dementia: A Randomized Controlled Trial

OBJECTIVES

Personal Assistive RObot (PARO) interventions have been used to treat agitation and mood symptoms of dementia effectively. However, the effects of a PARO intervention on physiological and cognitive function are unclear. To examine the effects of a group-based PARO intervention for older adults with mild dementia.

DESIGN

Using a group-based PARO intervention randomized controlled trial with 2-arm parallel groups.

SETTING AND PARTICIPANTS

Older adults with mild dementia aged 65 years or older from 4 dementia day care centers were recruited.

METHODS

Physiological parameters were assessed using the finger tapping test (FTT) and heart rate variability (HRV). The Mini-Mental State Examination (MMSE), Geriatric Depression Scale-Short Form (GDS-SF), University of California Los Angeles loneliness scale-version 3 (UCLA-3), and Warwick-Edinburgh Mental Well-being Scale (WEMWBS) were assessed before the intervention, end of the intervention, and 1-month after the intervention.

RESULTS

Using a repeated-measures generalized linear model, significant time × group interactions were found in the MMSE [F(2, 115) = 19.54, P < .001], FTT [F(2, 115) = 4.87, P = .01], HRV high-frequency [F(2, 115) = 3.57, P = .03], and high-frequency/low-frequency ratio [F(2, 115) = 0.96, P = .01], UCLA-3 [F(2, 115) = 54.7, P < .001], GDS-SF [F(2, 115) = 3.36, P = .04], and WEMWBS [F(2, 115) = 5.93, P < .001]. Furthermore, psychological parameters improved significantly and continuously even 1 month after the PARO intervention was finished. Physiological parameters significantly improved at week 6, but the effects had diminished by week 10.

CONCLUSIONS AND IMPLICATIONS

A PARO intervention may effectively improve the physiological and psychological responses of people with mild dementia.

Dementia and neurodegenerative diseases: What is known and what is promising at the cellular and molecular level

Millions of people worldwide are affected by neurodegenerative diseases and cognitive impairment, which includes dementia, while there are only symptomatic treatments available for this syndrome at present. However, several important prospective drug targets have been identified in recent years that can potentially arrest or even reverse the progression of neurodegenerative diseases. Their natural or synthetic ligands are currently in the experimental stage of drug development. In vitro and preclinical (e.g. using animal models) studies confirm their therapeutic potential, but clinical trials often fail or produce conflicting results. Here, we first review the complexity and typology of dementia, followed by the discussion of currently available treatments, and, finally, some novel molecular and cellular approaches to this problem.

The relationship between perceived engagement in meaningful activity and behavioral and psychological symptoms of dementia among assisted living residents

The purpose of this study is to assess the relationship between engagement in meaningful activities and behavioral and psychological symptoms of dementia (BPSD), including agitation, apathy, irritability, and depression among 71 assisted living (AL) residents with moderate to severe dementia. This secondary analysis used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD) in five AL communities. The Engagement in Meaningful Activities Scale and the Neuropsychiatric Inventory Questionnaire were completed. Logistic regression was used to compare those with and without each BPSD symptom of interest on engagement in meaningful activities while controlling for age, sex, and cognitive impairment. On average, participants were 85 years old, white, females. Perceived engagement in meaningful activities was significantly associated with decreased odds of having agitation (OR=0.94, 95 % CI [.88-0.99]) but not with apathy, depression, or irritability. Engagement in meaningful activities may help reduce agitation among AL residents.

Knowledge, Attitude, and Practice of Care Providers Toward Non-Pharmacological Intervention for Managing Behavioural and Psychological Symptoms in Australian Aged Care Residents with Dementia: A Cross-Sectional Survey

OBJECTIVES

This study aimed to assess the knowledge, attitude, and practice of the healthcare professionals and paid caregivers toward non-pharmacological interventions (NPIs) for managing behavioural and psychological symptoms of dementia (BPSD) in Australian residential aged care homes (RACHs).

METHODS

A cross-sectional, online survey was completed by RACH staff and physicians over the period 6 March-31 August 2023. Descriptive statistics were used to present the results.

RESULTS

Ninety-six respondents participated (41.7% aged 35-54 years, 80.2% female, 38.5% nurses). While 50-65% of the respondents were extremely familiar with 15 of NPIs, only 22% believed there was a sufficient funding for their implementation, and 6% felt there were sufficient human resources. Although 66% of the respondents viewed NPIs as more useful than medications, only 46% expected consistent positive outcomes from NPIs. The most used NPIs were redirection, behaviour management, and validation therapy.

CONCLUSIONS

The study highlights that barrier such as inadequate funding, limited human resources, skepticism about NPIs' effectiveness, unfamiliarity with certain NPIs, and unfavourable attitude toward NPIs are likely to slow NPI adoption for BPSD management.

CLINICAL IMPLICATION

To improve practice, it is essential to address these barriers through targeted education, and training, increased funding, and enhancement of the workforce.

Beta amyloid PET scans for dementia diagnoses: Practice and research implications from CARE-IDEAS

Beta amyloid PET scans are a minimally invasive biomarker that may inform Alzheimer's disease (AD) diagnosis. The Caregiver's Reactions and Experience (CARE) study, an IDEAS supplement, aimed to understand experiences of PET scan recipients and their care partners regarding motivations for scans, reporting and interpreting results, and impact of results. Patients with mild cognitive impairment or dementia who agreed to join the CARE-IDEAS study and their care partners participated in a baseline survey and follow-up survey approximately 18 months later, supplemented by in-depth qualitative interviews with subsets of participants. Patients who received scans and volunteered for follow-up research were more likely to be male, better educated, and have higher income than the general population. Survey information was merged with Medicare data. This article integrates findings from several CARE-IDEAS publications and provides implications for practice and research. Although most participants accurately reported scan results, they were often confused about their meaning for prognosis. Some participants reported distress with results, but there were no significant changes in measured depression, burden, or economic strain over time. Many respondents desired more information about prognosis and supportive resources. Scan results were not differentially associated with changes in service use over time. Findings suggest a need for carefully designed and tested tools for clinicians to discuss risks and benefits of scans and their results, and resources to support patients and care partners in subsequent planning. Learning of scan results provides a point-of-contact that should be leveraged to facilitate shared decision-making and person-centered longitudinal AD care.

Exploring the impact of care home environments and culture on supporting residents to 'wander' safely

OBJECTIVES

Up to 60% of people with dementia living in care homes will 'wander' at some point, which has typically been seen by staff as a problematic behaviour. A range of non-pharmacological interventions have been tested to either support or prevent wandering. However, even recent innovative practice continues to maintain a focus on reducing or preventing wandering. This study aimed to identify, for the first time, care home staff perspectives on home level factors that facilitate or hinder them supporting residents to wander safely.

METHOD

Semi-structured qualitative interviews were conducted with 19 care home staff, working in the North of England. Framework analysis was used to analyse the data.

RESULTS

A range of environmental considerations were identified by staff. Care home design influenced how residents were able to move safely around, and inclusion of points of interest encouraged walking to different locations, such as a garden. Staff worried about managing access to other residents' rooms by people who wander. Within the care home culture, prioritising safe staffing levels, training and awareness, involving external healthcare professionals where required and mentorship from experienced staff members, all contributed towards safe wandering. Staff support for positive risk-taking within the care home was key to promote person-centred care, alongside careful oversight and management of relationships between residents.

CONCLUSION

We identified a range of cultural and environmental factors that contribute towards safe wandering. A positive approach to risk-taking by staff is required to support residents to engage in wandering as an enjoyable activity, whilst acknowledging that there are inherent risks associated with this.

Investigating the impact of environmental enrichment on proteome and neurotransmitter-related profiles in an animal model of Alzheimer's disease

Alzheimer's disease (AD) is a neurodegenerative disorder associated with behavioral and cognitive impairments. Unfortunately, the drugs the Food and Drug Administration currently approved for AD have shown low effectiveness in delaying the progression of the disease. The focus has shifted to non-pharmacological interventions (NPIs) because of the challenges associated with pharmacological treatments for AD. One such intervention is environmental enrichment (EE), which has been reported to restore cognitive decline associated with AD effectively. However, the therapeutic mechanisms by which EE improves symptoms associated with AD remain unclear. Therefore, this study aimed to reveal the mechanisms underlying the alleviating effects of EE on AD symptoms using histological, proteomic, and neurotransmitter-related analyses. Wild-type (WT) and 5XFAD mice were maintained in standard housing or EE conditions for 4 weeks. First, we confirmed the mitigating effects of EE on cognitive impairment in an AD animal model. Then, histological analysis revealed that EE reduced Aβ accumulation, neuroinflammation, neuronal death, and synaptic loss in the AD brain. Moreover, proteomic analysis by liquid chromatography-tandem mass spectrometry showed that EE enhanced synapse- and neurotransmitter-related networks and upregulated synapse- and neurotransmitter-related proteins in the AD brain. Furthermore, neurotransmitter-related analyses showed an increase in acetylcholine and serotonin concentrations as well as a decrease in polyamine concentration in the frontal cortex and hippocampus of 5XFAD mice raised under EE conditions. Our findings demonstrate that EE restores cognitive impairment by alleviating AD pathology and regulating synapse-related proteins and neurotransmitters. Our study provided neurological evidence for the application of NPIs in treating AD.

Empowering a person-centered long-term care workforce

Currently there is a crisis in the long-term care workforce, as many workers experience poor pay, a lack of training, burnout, low quality working conditions, and physical strain, which is leading to a workforce shortage. To address this, the Alzheimer's Association Dementia Care Provider Roundtable (AADCPR) convened a panel of direct care workers to discuss and provide direction on their view of the current state of the workforce. From this panel, five touchpoints for hiring and retaining direct care workers were highlighted: high quality jobs; recruitment and reputation management; onboarding; retention; and training and career advancement. In addition, the DCPR put together a set of standards to follow to meet these needs, which includes promoting staff dementia education opportunities, creating recommendations around peer mentoring programs specific to dementia care, and increasing inclusion of direct care workers in decision-making and plans of care. HIGHLIGHTS: Presents the current state of workforce in long-term care. Provides five touchpoints that long-term and home and community-based services should implement for hiring and retaining direct care workers. Recommends a set of standards to follow to meet the needs of the workforce within long-term care.

Nurses' knowledge, attitude and practice regarding non-pharmacologic interventions for behavioral and psychological symptoms of dementia

BACKGROUND

To evaluate the knowledge, attitude and practice of nurses regarding non-pharmacologic therapies for behavioral and psychological symptoms of dementia (BPSD).

METHODS

This cross-sectional, questionnaire-based study enrolled nurses at Peking Union Medical College Hospital (Beijing, China) between September 2022 and October 2022. Correlations between knowledge, attitude and practice scores were evaluated by Pearson correlation analysis. Factors associated with knowledge, attitude and practice scores were identified by multivariable linear regression. Based on a cross-sectional questionnaire survey, this study designed a questionnaire according to the Guidelines for Diagnosis and Treatment of Dementia in China, and randomly selected nurses from Peking Union Medical College Hospital to fill in the questions through the Wen-Juan-Xing online platform from September 2022 to October 2022.

RESULTS

The analysis included 210 nurses (202 females). The average knowledge, attitude and practice scores were 11.06±2.61 (total score: 18), 53.51±5.81 (total score: 60) and 64.66 ± 10.35 (total score: 80) points, respectively. Knowledge score was positively correlated with attitude score (r = 0.416, P < 0.001) and practice score (r = 0.389, P < 0.001); attitude and practice scores were also positively correlated (r = 0.627, P < 0.001). Multivariable analysis demonstrated that age ≥ 40 years-old (vs. ≤30 years-old) was associated with higher knowledge score (β = 1.48, 95% confidence interval [95%CI] = 0.42-2.54, P = 0.006). Age ≥ 40 years-old (β = 1.43, 95%CI = 0.35-2.51, P = 0.010 vs. ≤30 years-old) and bachelor's degree or higher (β = 1.11, 95%CI = 0.12-2.10, P = 0.028 vs. college degree or lower) were associated with higher practice score.

CONCLUSIONS

Older age and higher education level were associated with higher knowledge, attitude and/or practice scores. The findings of this study may help guide the development and implementation of education and training programs to improve the management of BPSD by nurses in China.

Video Gaming in Older People: What Are the Implications for Cognitive Functions?

Mild cognitive impairment impacts a sizable segment of the older population, and often evolves into dementia within a few years. At this stage, subjects may benefit from non-pharmacological therapies that can delay or stop the progression of the mild cognitive impairment into dementia and are crucial for improvement in the subject's quality of life, while also being easily accessible and safe for use. Many research studies have shown that a variety of exercises, including cognitive training, have the potential to enhance or optimize cognitive function and general well-being. Recently, many authors have suggested video games as a promising approach for cognitive training and neurorehabilitation in older people, thanks to their increasing motivation and training effects through immersion in stimulating environments. Under this premise, our narrative review's objective is to discuss and summarize the body of existing material on the role of video games in improving cognitive performance, daily life activities, and depression symptoms in older individuals with different levels of cognitive decline. From the papers reviewed, it emerged that older subjects trained with video games showed a significant improvement in cognitive functions, sleep quality, and psychiatric symptoms, positioning video games as an intriguing and useful tool.

The current status of apathy in patients with dementia and its factors: A systematic review

OBJECTIVE

To systematically evaluate the current status of apathy in dementia patients and its associated factors.

METHODS

We searched Chinese and English databases to collect studies on the associated factors of apathy in patients with dementia from inception to March 14, 2023. Two researchers independently screened the literature, evaluated the quality, and extracted the data RESULTS: A total of 20 studies were included, and the incidence of apathy in patients with dementia ranged from 21 % to 90 %. According to the model of apathy proposed by Massimo in 2018, the associated factors were divided into individual factors for dementia patients, caregiver factors, and environmental factors. The individual factors of apathy in patients with dementia mainly include demographic characteristics, the severity of cognitive impairment, a combination of other behavioral and psychological symptoms of dementia, acute medical problems or adverse drug reactions, unmet needs, and malnutrition. Caregiver factors mainly include emotional expressions of hostility or criticism towards dementia patients and caregivers' expectations for a better life in the future. Environmental factors mainly include too high or too low stimulation and a lack of daytime activities CONCLUSIONS: Existing studies have shown that the incidence of apathy in dementia patients is high and is affected by multi-dimensional factors. There are more studies on individual factors in dementia patients and fewer studies on caregivers and environmental factors. In the future, a large number of high-quality studies are needed to demonstrate the mechanism of apathy in dementia patients and to find more related factors.

Increase in blood pressure precedes distress behavior in nursing home residents with dementia

BACKGROUND

Distress behaviors in dementia (DBD) likely increase sympathetic nervous system activity. The aim of this study was to examine the associations among DBD, blood pressure (BP), and intensity of antihypertensive treatment, in nursing home (NH) residents with dementia.

METHODS

We identified long-stay Veterans Affairs NH residents with dementia in 2019-20 electronic health data. Each individual with a BP reading and a DBD incident according to a structured behavior note on a calendar day (DBD group) was compared with an individual with a BP reading but without a DBD incident on that same day (comparison group). In each group we calculated daily mean BP from 14 days before to 7 days after the DBD incident day. We then calculated the change in BP between the DBD incident day and, as baseline, the 7-day average of BP 1 week prior, and tested for differences between DBD and comparison groups in a generalized estimating equations multivariate model.

RESULTS

The DBD and comparison groups consisted of 707 and 2328 individuals, respectively. The DBD group was older (74 vs. 72 y), was more likely to have severe cognitive impairment (13% vs. 8%), and had worse physical function scores (15 vs. 13 on 28-point scale). In the DBD group, mean systolic BP on the DBD incident day was 1.6 mmHg higher than baseline (p < .001), a change that was not observed in the comparison group. After adjusting for covariates, residents in the DBD group, but not the comparison group, had increased likelihood of having systolic BP > = 160 mmHg on DBD incident days (OR 1.02; 95%CI 1.00-1.03). Systolic BP in the DBD group began to rise 7 days before the DBD incident day and this rise persisted 1 week after. There were no significant changes in mean number of antihypertensive medications over this time period in either group.

CONCLUSIONS

NH residents with dementia have higher BP when they experience DBD, and BP rises 7 days before the DBD incident. Clinicians should be aware of these findings when deciding intensity of BP treatment.

Repurposing non-pharmacological interventions for Alzheimer's disease through link prediction on biomedical literature

Non-pharmaceutical interventions (NPI) have great potential to improve cognitive function but limited investigation to discover NPI repurposing for Alzheimer's Disease (AD). This is the first study to develop an innovative framework to extract and represent NPI information from biomedical literature in a knowledge graph (KG), and train link prediction models to repurpose novel NPIs for AD prevention. We constructed a comprehensive KG, called ADInt, by extracting NPI information from biomedical literature. We used the previously-created SuppKG and NPI lexicon to identify NPI entities. Four KG embedding models (i.e., TransE, RotatE, DistMult and ComplEX) and two novel graph convolutional network models (i.e., R-GCN and CompGCN) were trained and compared to learn the representation of ADInt. Models were evaluated and compared on two test sets (time slice and clinical trial ground truth) and the best performing model was used to predict novel NPIs for AD. Discovery patterns were applied to generate mechanistic pathways for high scoring candidates. The ADInt has 162,212 nodes and 1,017,284 edges. R-GCN performed best in time slice (MR = 5.2054, Hits@10 = 0.8496) and clinical trial ground truth (MR = 3.4996, Hits@10 = 0.9192) test sets. After evaluation by domain experts, 10 novel dietary supplements and 10 complementary and integrative health were proposed from the score table calculated by R-GCN. Among proposed novel NPIs, we found plausible mechanistic pathways for photodynamic therapy and Choerospondias axillaris to prevent AD, and validated psychotherapy and manual therapy techniques using real-world data analysis. The proposed framework shows potential for discovering new NPIs for AD prevention and understanding their mechanistic pathways.

Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care

BACKGROUND

Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups.

METHODS

This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis.

RESULTS

Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions.

CONCLUSIONS

This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.

Nonpharmacological nursing interventions for behavioural and psychological symptoms of dementia in acute and subacute settings: A systematic review

BACKGROUND

Behavioural and psychological symptoms of dementia are a group of non-cognitive symptoms such as agitation, physical aggression, depression, sexual disinhibition and psychosis. Therapeutic approaches vary because of the multifactorial and complex symptomology. The researchers of this study aimed to systematically review the nonpharmacological interventions for BPSD used by nurses in acute and subacute hospital settings.

DESIGN

The PRISMA guidelines guided this systematic review. The review was registered with PROSPERO (CRD42020184015).

METHOD

The databases Cumulative Index of Nursing and Allied Health Literature (CINAHL) complete, Medline complete, Excerpta Medica (Embase®) and PsycINFO published by the American Psychological Association (APA) were searched for studies published in English to October 2021. Quality appraisal was performed independently by three reviewers using the Critical Appraisal Skills Program tools. Data were synthesized using a narrative approach.

RESULTS

Two studies were identified that focused on interventions used by nurses; findings were positive for the use of nonpharmacological interventions to manage BPSD.

CONCLUSION

Current evidence suggests that nonpharmacological interventions are the best practices to manage BPSD. However, limited, and low-quality evidence suggests that further investigation is required to understand the factors contributing to the lack of use of nonpharmacological interventions by nurses in acute and subacute hospital settings.

Effects of multisensory environment/stimulation therapy on adults with cognitive impairment and/or special needs: A systematic review and meta-analysis

AIM

This review aimed to evaluate the effects of multisensory environments/stimulation (MSE/MSS) therapy, on the behavior and psychological symptoms in adults with cognitive impairment and/or special needs.

METHODS

Online database searches were performed to identify studies reporting on the effects of MSS/MSE therapy in adults (>18 years). Data were extracted for the following investigated outcomes including anxiety, depression, mood, behavioral attributes, biomedical parameters, cognition, motor skills, quality of life (QoL), pain, and end of life quality. Two reciprocally blinded investigators extracted the data. Inter-investigator reliability (𝝹) was calculated. A meta-analysis and a qualitative analysis were performed on the information extracted.

RESULTS

Thirty-six studies were included for data extraction and analysis. Meta-analysis of the included studies revealed a significant improvement with the MSE/MSS therapy, for agitation (p = .018), anxiety (p = .023), cognition (p < .001), and depression (p < .001). MSS/MSE therapy demonstrated a tendency for the improvement of the QoL in adults (p = .05).

CONCLUSION

MSE/MSS therapies are beneficial in cognitively impaired adults and improve their anxiety, depression, cognitive and other behavioral attributes such as agitative behaviors. Promoting these therapies in geriatric care may help to improve/reduce the challenging/care-resistant behaviors in adults and facilitate effective provision of the necessary care.

Using Structured Observations to Evaluate the Effects of a Personalized Music Intervention on Agitated Behaviors and Mood in Nursing Home Residents With Dementia: Results From an Embedded, Pragmatic Randomized Controlled Trial

OBJECTIVE

The objective of this research was to determine if a personalized music intervention reduced the frequency of agitated behaviors as measured by structured observations of nursing home (NH) residents with dementia.

DESIGN

The design was a parallel, cluster-randomized, controlled trial.

SETTING

The setting was 54 NH (27 intervention, 27 control) from four geographically-diverse, multifacility NH corporations.

PARTICIPANTS

The participants were 976 NH residents (483 intervention, 493 control) with Alzheimer's disease or related dementias (66% with moderate to severe symptoms); average age 80.3 years (SD: 12.3) and 25.1% were Black.

INTERVENTION

The intervention was individuals' preferred music delivered via a personalized music device.

MEASUREMENT

The measurement tool was the Agitated Behavior Mapping Instrument, which captures the frequency of 13 agitated behaviors and five mood states during 3-minute observations.

RESULTS

The results show that no verbally agitated behaviors were reported in a higher proportion of observations among residents in NHs randomized to receive the intervention compared to similar residents in NHs randomized to usual care (marginal interaction effect (MIE): 0.061, 95% CI: 0.028-0.061). Residents in NHs randomized to receive the intervention were also more likely to be observed experiencing pleasure compared to residents in usual care NHs (MIE: 0.038; 95% CI: 0.008-0.073)). There was no significant effect of the intervention on physically agitated behaviors, anger, fear, alertness, or sadness.

CONCLUSIONS

The conclusions are that personalized music may be effective at reducing verbally-agitated behaviors. Using structured observations to measure behaviors may avoid biases of staff-reported measures.

The longitudinal relationship between levels of cognitively stimulating leisure activity and positive and negative affect among older adults with MCI

BACKGROUND

The purpose of this study was to investigate the longitudinal relationship between different levels of cognitively stimulating leisure activity (CSLA) participation and different levels of positive and negative affect among older adults with mild cognitive impairment (MCI).

METHODS

Using a repeated-measured multivariate analysis of covariance (RM-MANCOVA), this study analyzed the Health and Retirement Study (HRS) data from 2012 to 2020 (N = 5932).

RESULTS

The results presented the following. (a) The high CSLA group showed higher positive affect and lower negative affect than the mid and low groups. Also, the mid-CSLA group presented higher positive affect and lower negative affect than the low CSLA group. (b) Both positive and negative affect showed significant differences between years and indicated a continuously declining slope year by year without exceptions. (c) The high CSLA group not only presented higher positive affect and lower negative affect during the period but also solely showed a rebounding feature in the declining slope on both emotions.

CONCLUSIONS

The findings of this study provide valuable support for the design and implementation of CSLA participation programs and clinical guidelines for older adults with MCI. The results highlight the importance of determining the optimal level of CSLA engagement that is required to promote emotional health and cognitive function in this population. Healthcare professionals and clinical practitioners can leverage the insights gained from this study to develop and deliver effective CSLA interventions tailored to the specific needs and capacities of older adults with MCI.

A Framework for Assessing the Effects of Climate Change on Dementia Risk and Burden

Alzheimer's disease and related dementias (ADRD) represent a public health crisis poised to worsen in a changing climate. Substantial dementia burden is modifiable, attributable to risk rooted in social and environmental conditions. Climate change threatens older populations in numerous ways, but implications for cognitive aging are poorly understood. We illuminate key mechanisms by which climate change will shape incidence and lived experiences of ADRD, and propose a framework for strengthening research, clinical, and policy actions around cognitive health in the context of climate change. Direct impacts and indirect risk pathways operating through built, social, interpersonal, and biomedical systems are highlighted. Air pollution compromises brain health directly and via systemic cardiovascular and respiratory ailments. Flooding and extreme temperatures constrain health behaviors like physical activity and sleep. Medical care resulting from climate-related health shocks imposes economic and emotional tolls on people living with dementia and caregivers. Throughout, inequitable distributions of climate-exacerbated risks and adaptive resources compound existing disparities in ADRD incidence, comorbidities, and care burden. Translational research, including work prioritizing underserved communities, is crucial. A mechanistic framework can guide research questions and methods and identify clinical- and policy-level intervention loci for prevention and mitigation of climate-related impacts on ADRD risk and burden.

[Validation for people with dementia: innovation without evidence? : Systematic review]

BACKGROUND

Validation was an innovative approach to dealing with people with dementia that was supposed to reduce the incidence of challenging behavior. This effect, however, remains unclear to this day.

OBJECTIVE

Does validation reduce challenging behaviour in people with dementia?

MATERIAL AND METHOD

Systematic review according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Literature search in PubMed, CINAHL, PsycInfo and Web of Science. Description and critical appraisal of identified studies by two reviewers using the revised Cochrane risk of bias tool for randomized controlled trials.

RESULTS

A total of five studies were identified. Only one showed a significant reduction in challenging behavior compared to the control group. All studies had a moderate to high risk of bias.

CONCLUSION

Despite the negative results, a positive effect of validation cannot be ruled out as the trials tested validation as an isolated treatment and not as an integrated part of daily care. In addition, blinding, which is common in clinical trials, is not an appropriate criterion for evaluating trials investigating interventions where the effects result exclusively from interpersonal interaction.

Virtual Reality-Based Education Program for Managing Behavioral and Psychological Symptoms of Dementia: Development and Feasibility Test

This study aims to develop a virtual reality-based education program for managing behavioral and psychological symptoms of dementia for family carers of persons living with dementia and investigate the feasibility for users. The program was developed through literature review, interviews with family carers, surveys, and expert content validity assessment. User feasibility was evaluated quantitatively through a questionnaire on usefulness, ease of use, and satisfaction, and qualitatively through participant interviews. The program was produced in two parts, Type 1 and Type 2, consisting of three and six episodes, respectively. Participants showed a high level of satisfaction with overall program scores of 4.28 ± 0.66 and 4.34 ± 0.41 for the two evaluations. Participants also expressed that both programs were helpful, Type 1 for achieving changes in attitude associated with more understanding of persons living with dementia and Type 2 for acquiring coping methods through communication training. Use of the virtual reality device was not inconvenient and was identified as helpful due to the high immersion experience. Results of this study confirmed that family carers had no resistance to education using new technologies such as virtual reality devices and that virtual reality-based education could be effective for training family carers.

Nonpharmacological interventions in dementia and diversity of samples: A scoping review

BACKGROUND

A public health priority is the increasing number of people with dementia (PwD), and nonpharmacological interventions (NPIs) might offer support. We sought to synthesize types of NPIs tested among PwD and explore sample characteristics.

METHODS

This study was a scoping literature review. Eligible articles were identified using the search terms "nonpharmacological intervention" and "dementia".

RESULTS

36 articles were included. Psychosocial NPIs were implemented the most (n=24) and music-based interventions were found to be the most effective. Gender, race, and ethnicity were not consistently reported (n=30, n=24, and n=6, respectively). White PwD had higher representation, with only 62.5% of studies including Black participants and 25% including Hispanic/Latino participants. Women made up a majority (>50%) of the sample in a greater number of studies (n=20).

CONCLUSION

Findings suggest that future studies need to be intentional about improving diversity of the sample, particularly with respect to including persons identifying as Black or Hispanic/Latino.

Use of Virtual Reality to Improve Spatial Orientation in Alzheimer's Disease and Mild Cognitive Impairment: A Systematic Review

BACKGROUND

Alzheimer's disease is a chronic, neurodegenerative condition that leads to a significant cognitive decline. One of the symptoms that greatly reduces the quality of daily functioning is the deterioration of spatial orientation abilities. A non-pharmacological treatment option for Alzheimer's disease, which is also employed to improve the cognitive functioning of individuals with mild cognitive impairment, is virtual reality training.

OBJECTIVE

To the best of the authors' knowledge, there is no existing systematic review on the use of virtual reality training to enhance spatial orientation in individuals with Alzheimer's disease or mild cognitive impairment. The review was therefore conducted to fill this gap. The findings of this review may support the efficacy of virtual reality in enhancing spatial orientation.

METHODS

Five databases were searched. The primary inclusion criteria were study participants aged over 60 years with a diagnosis of Alzheimer's disease or mild cognitive impairment and the use of virtual reality for improving spatial orientation. Six studies meeting these criteria were ultimately included in the review.

RESULTS

All included studies demonstrated an improvement in the spatial orientation of individuals with Alzheimer's disease or mild cognitive impairment following virtual reality training. This indicates the effectiveness of virtual reality technology in cognitive rehabilitation.

CONCLUSION

As virtual reality cognitive training has proven effective, its use should be more widely adopted. Further research on the application of virtual reality for enhancing spatial orientation in individuals with dementia is recommended.

Examining the Feasibility and Acceptability of Digital Cognitive Stimulation Therapy for Dementia Care in Jordan: A Qualitative Study

Introduction

The use of technology to deliver psychosocial interventions such as cognitive stimulation therapy (CST) to individuals with dementia may improve their cognition and quality of life.

Objectives

This study aimed to investigate the participants' experiences with digital CST in Jordanian care homes, as well as the acceptability of the digital CST intervention in Jordanian care homes and recommendations for refinement.

Methods

A qualitative study design and semistructured interviews were used to obtain data from 20 people with dementia and 12 care home staff who were purposefully selected. Data were analyzed thematically and comparatively to explore the experiences and outcomes of the participants. This study was conducted from February to April 2023.

Results

Analysis of care home staff and residents' experiences revealed seven major themes: (a) personalized support and engagement, (b) positive impact on quality of life, (c) engagement and meaningful activities, (d) adaptable format and accessibility, (e) emotional connection and empowerment, (f) caregiver involvement and support, and (g) suggestions for improvement. The study's findings emphasize the necessity of tailored support, individualized difficulty levels, individualized material selection, emotional support, greater social connection, and caregiver participation in digital CST for people with dementia.

Conclusion

Using digital touchscreen technology to deliver CST content has shown potential improvements, making interventions simpler for staff and more beneficial for individuals with dementia, thereby enhancing cognition and quality of life.

Development of the Dardashna Checklist for Identifying Triggers of Behavioral Change in Individuals With Dementia: A Qualitative Study

The purpose of the current qualitative study was to describe the development of the Dardashna Checklist to clinically identify behavior change triggers in individuals with dementia. Semi-structured, in-depth, face-to-face interviews were conducted with four physicians and four experienced caregivers involved in the care of individuals with dementia. From analysis of participants' interviews, themes extracted included Triggers of Behavioral Change in Individuals With Dementia and Types of Behavioral Changes, using the checklist structure as a guide. The information gathered by this checklist conveys important messages to experienced physicians or caregivers who want to help less experienced caregivers or individuals with dementia. In this case, physicians' prescriptions and the responses of other experienced caregivers will be more targeted and useful. This checklist will help facilitate clinical care decisions, improve quality of life, reduce expenses and side effects of medications, and improve communication among persons with dementia, their caregivers, and health care providers. [Journal of Gerontological Nursing, 50(1), 37-46.].

Can Residents With Late-Stage Dementia Still Engage?

Institutionalized persons with dementia often lack access to meaningful activity, which can lead to agitation, loneliness, and depression. Engagement in activity may improve negative symptoms but is difficult in most settings. In this study, we investigated the degree to which the Reading Buddies Program, in which occupational therapy graduate students read books with residents with dementia, engaged residents. We further assessed whether the level of engagement was affected by various parameters, including those related to interaction, environment, attention, attitude, and activity. The primary outcome measure was engagement percentage-duration of time the book was read divided by duration of time the person with dementia engaged with the book. As expected, increased attention, attitude, and activity parameters were associated with increased engagement. None of the environmental parameters significantly affected engagement. Overall, we found that reading with persons with dementia led to a very high level of engagement and appeared to reduce negative symptoms.

BPSD reconsidered: diagnostic considerations to preserve personhood in persons with dementia

BPSD is relatively common but profoundly disturbing to persons with dementia, their family, and caregivers. Growing recognition of the impact of BPSD on quality of life has improved recently, but assessment and management approaches are still lacking. Considerable controversy surrounding the label of BPSD has garnered a great deal of attention, with implications of its contribution to the already pervasive dementia-related stigma experienced by persons with dementia and their caregivers. This brief review aims to summarize salient viewpoints, controversies, and considerations of the assessment, management, and perception of BPSD, in an effort to offer potential recharacterizations of BPSD to promote and prioritize personhood in persons with dementia.

Factors Affecting Physical Activity in People with Dementia: A Systematic Review and Narrative Synthesis

Physical activity (PA) has positive effects on the physical and cognitive functioning of people with dementia. Knowledge about what limits and stimulates people with dementia to participate in PA is essential to promote effective PA implementation and enhance PA levels. Previous reviews primarily included opinion-based studies, using data from interviews, focus groups or dyads. By including implementation studies, we aimed to elaborate on previous reviews by identifying new barriers to PA and new facilitators and motivators for PA. We conducted systematic searches in Pubmed, PsychInfo and Web of Science for studies published up to the 21st of September 2021. Search terms were related to the population of people with dementia, PA interventions and implementation outcomes. Studies were included if PA participation was investigated during actual PA implementation. No restrictions were made regarding study design, date of publication, PA type or outcome measures. Studies not implementing PA or not evaluating the implementation were excluded. Based on 13 empirical studies, we identified 35 barriers, 19 facilitators and 12 motivators. Of these, 21 barriers, 11 facilitators and 4 motivators were not identified by previous reviews. New factors are related to the support for people with dementia from informal and formal caregivers, e.g., revealing the importance of a trusting relationship. Furthermore, support for staff from the institution or an external party is needed to overcome doubts about PA, for example, related to safety and effects. New factors also suggested specific recommendations for the content and organization of the PA intervention, for instance, related to how to give instructions. Overall, factors affecting PA identified with opinion-based or implementation studies are complementary. Our extended overview shows the complexity of PA implementation and may help to personalize PA, develop implementation strategies, facilitate actual PA implementation and free up resources needed for effective implementation.

Clinical factors associated with the quality of interactions between staff and hospitalized older patients with dementia

This study examines the clinical factors associated with the quality of interactions between staff and hospitalized older patients with dementia. Following examination of bivariate associations, we conducted multiple linear regression in a sample of 140 hospitalized older patients with dementia who participated in the final cohort of an intervention study implementing Family-centered Function-focused Care (Fam-FFC). On average, the participants (male = 46.1%, female = 52.9%) were 81.43 years old (SD = 8.29) and had positive interactions with staff (mean QUIS score = 5.84, SD = 1.36). Accounting for 17.8% of variance in the model, non-pharmacological intervention use (b= 0.170; p<.001) and pain (b= -0.198; p<.01) were significantly associated with the quality of staff-patient interactions. To optimize care of hospitalized patients with dementia, staff should be encouraged to use non-pharmacological interventions. It is also important for staff to assess pain among the patients with dementia and prioritize pain management.

Nursing assistants' use of best practices and pain in older adults living in nursing homes

BACKGROUND

Inadequate pain management persists in nursing homes. Nursing assistants provide the most direct care in nursing homes, and significantly improving the quality of care requires their adoption of best care practices informed by the best available evidence. We assessed the association between nursing assistants' use of best practices and residents' pain levels.

METHODS

We performed a cross-sectional analysis of data collected between September 2019 and February 2020 from a stratified random sample of 87 urban nursing homes in western Canada. We linked administrative data (the Resident Assessment Instrument-Minimum Data Set [RAI-MDS], 2.0) for 10,093 residents and survey data for 3547 nursing assistants (response rate: 74.2%) at the care unit level. Outcome of interest was residents' pain level, measured by the pain scale derived from RAI-MDS, 2.0. The exposure variable was nursing assistants' use of best practices, measured with validated self-report scales and aggregated to the unit level. Two-level random-intercept multinomial logistic regression accounted for the clustering effect of residents within care units. Covariates included resident demographics and clinical characteristics and characteristics of nursing assistants, unit, and nursing home.

RESULTS

Of the residents, 3305 (30.3%) were identified as having pain. On resident care units with higher levels of best practice use among nursing assistants, residents had 32% higher odds of having mild pain (odds ratio, 1.32; 95% confidence interval, 1.01-1.71; p = 0.040), compared with residents on care units with lower levels of best practice use among nursing assistants. The care units did not differ in reported moderate or severe pain among residents.

CONCLUSIONS

We observed that higher unit-level best practice use among nursing assistants was associated with mild resident pain. This association warrants further research to identify key individual and organizational factors that promote effective pain assessment and management.

Recent advances in understanding Alzheimer's Disease: diagnosis and management strategies

As the rates of Alzheimer's Disease (AD) increase in the world due to the aging of the population, research has made tremendous advances to target the two hallmark pathologies of AD: amyloid-β (Aβ) plaque deposition and neurofibrillary tangles of hyperphosphorylated tau. Here, we discuss recent advances in the clinical evaluation and management of AD, with a focus on new hypotheses related to the etiology of AD and new evidence related to AD-mimicking neurodegenerative diseases. Though recent clinical studies suggest anti-amyloid disease modifying agents may slow the progression of AD, there is currently no medication that stops it. Moreover, slowing the progression will result in more individuals in the mild cognitive impairment (MCI) and mild dementia stages of AD. Given this reality, we evaluate the development of non-pharmacological strategies to help sustain cognitive function and quality of life.

The impact of aromatherapy-based oral care on oral conditions, salivary pH, and halitosis in older adults with dementia: Pilot study

Inadequate oral care and poor oral health in older adults are known to increase the risk of dementia. Dementia patients residing in long-term care facilities are especially vulnerable to oral diseases due to their care-resistant behavior. This study aimed to investigate the effects of a 7-day oral care program based on an aroma solution in 58 dementia patients (29 each in the experimental and control groups) admitted to a long-term care hospital in South Korea. The experimental group received oral care with a solution containing peppermint, tea tree, and lemon essential oils, and the control group with a saline solution. The effectiveness of oral care was assessed by the participants' oral condition, salivary pH, and halitosis. The experimental group showed significant improvements (P<.001) in all three outcomes, indicating that oral care with an aroma solution can improve the oral health of older dementia patients residing in long-term care facilities.

Psychosocial interventions for reducing antipsychotic medication in care home residents

BACKGROUND

Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012.

OBJECTIVES

To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13.

COSTS

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not.

AUTHORS' CONCLUSIONS

All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.

Effects of Robot-Assisted Activity Using a Communication Robot on Neurological Activity in Older Adults with and without Cognitive Decline

Robot-assisted activity (RAA) using a communication robot (RAA-CR) has been proposed as a tool for alleviating behavioral and psychological symptoms accompanying dementia (BPSD) in patients with cognitive decline. This study aimed to clarify the effects of differences in cognitive function among older adults on changes in active brain areas induced by RAA-CR. Twenty-nine older adults were divided into a cognitive decline group (n = 11) and a control group (n = 18). The participants individually received a 5-minute RAA session, and their resting EEG activity was measured before and after the session. Brain spatial analysis was performed on recorded EEG data using standardized low-resolution brain electromagnetic tomography. In addition, statistical comparisons of neural activity in the brain were made before and after RAA-CR and between the cognitively impaired and control groups. These results suggest that RAA-CR stimulates neural activity in the region centered on the posterior cingulate gyrus and precuneus in cognitively healthy older adults but does not significantly alter brain neural activity in cognitively impaired older adults. Therefore, modifications to the implementation methods may be necessary to effectively implement RAA-CR in cognitively impaired individuals.

Effects of methylphenidate on neuropsychiatric symptoms in Alzheimer's disease: Evidence from the ADMET 2 study

INTRODUCTION

Methylphenidate has been shown to improve apathy in patients with Alzheimer's disease (AD). The authors evaluated the impact of methylphenidate on neuropsychiatric symptoms (NPS) of AD, excluding apathy, using data from the Apathy in Dementia Methylphenidate Trial 2 (ADMET 2) study.

METHODS

A secondary analysis was conducted on data from the ADMET 2 study to determine the effect of methylphenidate on Neuropsychiatric Inventory (NPI) scores outside of apathy. Caregiver scores were compared from baseline to month 6 in 199 participants receiving methylphenidate (20 mg/day) or placebo regarding the presence or absence of individual neuropsychiatric symptoms, emergence of new symptoms, and individual domain scores.

RESULTS

No clinically meaningful improvement was observed in any NPI domain, excluding apathy, in participants treated with methylphenidate compared to placebo after 6 months. A statistical difference between groups was appreciated in the domains of elation/euphoria (P = 0.044) and appetite/eating disorders (P = 0.014); however, these findings were not considered significant.

DISCUSSION

Methylphenidate is a selective agent for symptoms of apathy in patients with AD with no meaningful impact on other NPS. Findings from this secondary analysis are considered exploratory and multiple limitations should be considered when interpreting these results, including small sample size and use of a single questionnaire.HIGHLIGHTS: Methylphenidate was not associated with significant improvement on the Neuropsychiatric Inventory in domains outside of apathy.Methylphenidate did not show a statistically significant emergence of new neuropsychiatric symptoms (NPS) throughout the 6-month treatment period compared to placebo.Methylphenidate appears to be a highly selective agent for apathy in Alzheimer's disease, potentially supporting catecholaminergic dysfunction as the driving force behind this presentation of symptoms.

Repurposing Non-pharmacological Interventions for Alzheimer's Diseases through Link Prediction on Biomedical Literature

Recently, computational drug repurposing has emerged as a promising method for identifying new pharmaceutical interventions (PI) for Alzheimer's Disease (AD). Non-pharmaceutical interventions (NPI), such as Vitamin E and Music therapy, have great potential to improve cognitive function and slow the progression of AD, but have largely been unexplored. This study predicts novel NPIs for AD through link prediction on our developed biomedical knowledge graph. We constructed a comprehensive knowledge graph containing AD concepts and various potential interventions, called ADInt, by integrating a dietary supplement domain knowledge graph, SuppKG, with semantic relations from SemMedDB database. Four knowledge graph embedding models (TransE, RotatE, DistMult and ComplEX) and two graph convolutional network models (R-GCN and CompGCN) were compared to learn the representation of ADInt. R-GCN outperformed other models by evaluating on the time slice test set and the clinical trial test set and was used to generate the score tables of the link prediction task. Discovery patterns were applied to generate mechanism pathways for high scoring triples. Our ADInt had 162,213 nodes and 1,017,319 edges. The graph convolutional network model, R-GCN, performed best in both the Time Slicing test set (MR = 7.099, MRR = 0.5007, Hits@1 = 0.4112, Hits@3 = 0.5058, Hits@10 = 0.6804) and the Clinical Trials test set (MR = 1.731, MRR = 0.8582, Hits@1 = 0.7906, Hits@3 = 0.9033, Hits@10 = 0.9848). Among high scoring triples in the link prediction results, we found the plausible mechanism pathways of (Photodynamic therapy, PREVENTS, Alzheimer's Disease) and (Choerospondias axillaris, PREVENTS, Alzheimer's Disease) by discovery patterns and discussed them further. In conclusion, we presented a novel methodology to extend an existing knowledge graph and discover NPIs (dietary supplements (DS) and complementary and integrative health (CIH)) for AD. We used discovery patterns to find mechanisms for predicted triples to solve the poor interpretability of artificial neural networks. Our method can potentially be applied to other clinical problems, such as discovering drug adverse reactions and drug-drug interactions.

Machine learning-based predictive models for the occurrence of behavioral and psychological symptoms of dementia: model development and validation

The behavioral and psychological symptoms of dementia (BPSD) are challenging aspects of dementia care. This study used machine learning models to predict the occurrence of BPSD among community-dwelling older adults with dementia. We included 187 older adults with dementia for model training and 35 older adults with dementia for external validation. Demographic and health data and premorbid personality traits were examined at the baseline, and actigraphy was utilized to monitor sleep and activity levels. A symptom diary tracked caregiver-perceived symptom triggers and the daily occurrence of 12 BPSD classified into seven subsyndromes. Several prediction models were also employed, including logistic regression, random forest, gradient boosting machine, and support vector machine. The random forest models revealed the highest area under the receiver operating characteristic curve (AUC) values for hyperactivity, euphoria/elation, and appetite and eating disorders; the gradient boosting machine models for psychotic and affective symptoms; and the support vector machine model showed the highest AUC. The gradient boosting machine model achieved the best performance in terms of average AUC scores across the seven subsyndromes. Caregiver-perceived triggers demonstrated higher feature importance values across the seven subsyndromes than other features. Our findings demonstrate the possibility of predicting BPSD using a machine learning approach.

Emotion-focused dyadic coping styles used by family carers of people with dementia during the COVID-19 pandemic

Emotional wellbeing of family carers and people with dementia is associated with not only how each individual copes with stress and conflict, but also by how they cope together. Finding ways to positively cope together was particularly important during COVID-19 lockdown restrictions, when other avenues of emotional support were less available. We explored how carers experienced and used emotion-focused dyadic coping styles during the COVID-19 pandemic. In-depth qualitative interviews were conducted during the pandemic with 42 family carers, supplemented by quality of life scores collected both pre- and during the pandemic and household status. Abductive thematic analysis identified five styles of emotion-focused dyadic coping: common, supportive, hostile, disengaged avoidance and protective. The COVID-19 pandemic left many dyads unsupported. While many carers adapted, reporting increases in quality of life and enjoying the extra time with the person with dementia, others experienced dyadic conflict and reductions in quality of life. This variation was associated with dyadic coping styles, including challenges in using 'positive' styles and the protective use of 'negative' disengaged avoidance in the right situations. Dyadic coping styles also differed as a function of whether the dyad lived together. As many people with dementia are supported by an informal carer, considering how they cope together could help us to better support them. We make suggestions for dyadic interventions tailored by co-residency status that could help dyads identify and communicate coping needs, reconnect following avoidance coping, and replenish their coping resources through social support.

Identifying Factors Affecting the Sustainability of the STAR-VA Program in the Veterans Health Administration

BACKGROUND AND OBJECTIVES

Sustained implementation of new programs in complex care systems like nursing homes is challenging. This prospective qualitative evaluation examined factors affecting the sustainability of the Staff Training in Assisted Living Residences in Veterans Health Administration (STAR-VA) program in Veterans Health Administration (VA) Community Living Centers (CLC, i.e., nursing homes). STAR-VA is an evidence-based interdisciplinary, resident-centered, behavioral approach for managing distress behaviors in dementia.

EVALUATION DESIGN AND METHODS

In 2019, we conducted 39 semistructured phone interviews with STAR-VA key informants across 20 CLCs. We identified a priori themes based on the Organizational Memory Framework, which includes 7 Knowledge Reservoirs (KRs): people, routines, artifacts, relationships, organizational information space, culture, and structure. We conducted content-directed analysis of transcripts to identify factors to program sustainment.

RESULTS

We identified 9 sustainment facilitators across KRs: engaged site leaders and champions, regular meetings and trainings, written documentation and resources, regular and open communication, available educational tools (e.g., handouts and posters), adequate spaces, leadership support on many levels, staff buy-in across disciplines, and staff competencies and recognition. Ten barriers across KRs included: staffing concerns, inconsistent/inefficient routines, inconsistent documentation, lack of written policies, communication gaps, nonstandardized use of tools, constraints with meeting spaces and regulations on posting information, limited leadership support, division among staff, and missing performance expectations.

DISCUSSION AND IMPLICATIONS

Findings inform tailored strategies for optimizing STAR-VA program sustainment in CLCs, including the development of a sustained implementation guide, implementation resources, regional communities of practice, and STAR-VA integration into national CLC quality improvement routines for team communication and problem-solving.