Comparative efficacy of multiple non-pharmacological interventions for behavioural and psychological symptoms of dementia: A network meta-analysis of randomised controlled trials

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.

The use and effect of virtual reality as a non-pharmacological intervention for behavioural and psychological symptoms of dementia: a systematic review and meta-analysis

BACKGROUND

Behavioural and psychological symptoms of dementia (BPSD) are complex neuropsychiatric symptoms that contribute to caregiver strain, increased rates of institutionalisation and reduced quality of life. Virtual reality (VR) has gained interest as a non-pharmacological approach to potentially reduce BPSD severity.

OBJECTIVE

This review sought to synthesise evidence on the effectiveness of VR in reducing BPSD severity, while exploring its acceptability, safety, and optimal dosage in dementia care.

METHODS

MEDLINE, EMBASE, CINAHL and SCOPUS were searched for randomised and quasi-experimental trials assessing VR's effect on BPSD. JBI critical appraisal checklists were used to assess methodological quality. Findings were presented narratively, with meta-analysis performed on a subset of BPSD symptoms where data were available.

RESULTS

Of the ten included studies, four found no significant change in overall BPSD. Mixed findings were observed for individual BPSD symptoms. Meta-analysis showed a significant reduction in depressive symptoms (mean diff -0.38, P= .026) and no reduction in agitation (mean diff 1.87, P = .2). Two studies reported reduced aggression and mixed findings were found for anxiety. Reduced apathy was observed in one study following each VR session and during the session in another. VR was generally well-accepted with few side effects reported.

CONCLUSION

VR appears to be an acceptable non-pharmacological intervention for BPSD reduction. However, the limited available studies, methodological variations and quality issues suggest the need for future larger-scale research to confirm its efficacy and effectiveness.

Shadow puppetry therapy enhances dementia-related cognitive function and interpersonal relationship

BACKGROUND

With the growing demand for dementia care, non-pharmacological interventions, such as creative arts therapies, have been proven effective in stabilizing cognitive function. Shadow Puppetry Therapy (SPT), which integrates visual, auditory, and kinesthetic elements, offers a promising care option for individuals with dementia.

OBJECTIVE

This study evaluated the effectiveness of SPT on cognitive function, self-esteem, and interpersonal relationships among older adults with mild dementia.

METHODS

We adopted a quasi-experimental design and recruited 33 older adults with mild dementia from two dementia care centers. Older adults with mild dementia were randomly assigned to an experimental group (n = 15) and a control group (n = 18). The experimental group participated in a 16-week SPT program, and the control group engaged in regular activities, such as physical exercises, painting, cooking, music, and handicraft projects. Assessments included the short portable mental status questionnaire (SPMSQ), the Rosenberg self-esteem scale (RSES), and the interpersonal relationship scale, with evaluations conducted before and after the intervention.

RESULTS

The intervention significantly improved cognitive function, self-esteem, and interpersonal relationships in the experimental group. SPMSQ scores decreased, indicating enhanced cognitive function (p = .001), while self-esteem and interpersonal relationship scores showed significant improvements (p = .001). No significant changes were observed in the control group.

CONCLUSION

SPT is an effective non-pharmacological intervention for enhancing cognitive function, self-esteem, and interpersonal relationships in older adults with mild dementia. The findings support the integration of creative arts therapies into dementia care.

Different physical exercise in the treatment of Alzheimer's disease

Alzheimer's disease (AD) is rapidly becoming one of the most expensive, burdening, and deadly diseases of this century. Up to now, there is still a lack of pharmacotherapy with substantial efficacy, and physical exercise is a promising and low-cost way to aid in delaying the process of AD. The aim of this review is to summarise the efficacy of different physical exercise approaches and doses in the management of AD, including aerobic exercise, resistance exercise and multicomponent exercise. A literature search using MeSH terms for each topic is undertaken using PubMed and the Web of Science Core Collection database, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesised, and summarised. This review shows that aerobic exercise has been almost unanimously recognised for the improvement of cognition, neuropsychiatric symptoms and activities of daily living. Resistance exercise also shows a good prospect in the above aspects and has a unique advantage in enhancing muscle strength, while multicomponent physical activity does not seen to significantly improve cognitive function. Each type of exercise has a dose effect, but for individuals with AD, the most appropriate exercise dose is still controversial.

Person-centered care at population scale: The Swedish registry for behavioral and psychological symptoms of dementia

INTRODUCTION

Behavioral and psychological symptoms of dementia (BPSD) are a common driver of suffering and high care needs. We describe the Swedish BPSD registry, founded in 2010 to develop an evidence base for quality improvement in the care of patients with BPSD. Further, we illustrate the potential of the registry by evaluating how individual BPSD affects mortality.

METHODS

The registry provides a framework for documenting the occurrence of BPSD, formulating individual care plans, and following up outcomes. Symptoms are recorded by the nursing home version of the neuropsychiatric inventory (NPI), and data are entered by trained staff, mainly at institutional care facilities.

RESULTS

Enrollment in the registry totaled 114,869 patients with dementia and a mean age of 84 years. Patients were followed until death (median overall survival 2.2 years) or loss to follow-up (median time under observation 4.2 years in patients remaining alive). Common symptoms included agitation/aggression, aberrant motor behavior, and irritability. Mortality increased with NPI severity and use of neuroleptics but decreased in patients receiving cholinesterase inhibitors or memantine.

DISCUSSION

The scale, completeness, and duration of the registry, together with the possibility of linking to other data sources, offer great potential for data-driven research.

Highlights

The Swedish BPSD Registry, founded in 2010, has followed over 114,000 patients collecting data on symptoms, care plans, interventions and outcomes.The registry provides a framework for providing and evaluating person-centered care for patients with BPSD, and represents an unparalleled data source for research into BPSD and its management.Mortality increased in patients with more severe BPSD symptoms and for those treated with neuroleptics, but decreased in patients receiving cholinesterase inhibitors or mematine.

Defining and Categorizing Nonpharmacologic Interventions in the Older Population: A Systematic Review

OBJECTIVES

Nonpharmacologic interventions (NPIs) constitute an important part of treatment for older adults, cover a broad and diverse range of interventions, and have advantages over pharmacologic interventions (eg, limited adverse side effects). However, an unambiguous definition of NPIs is still lacking. Defining NPIs may facilitate research on this topic and enhance comparability of results between studies, and might help to face the challenges of recognition, acceptation, funding, and implementation. Therefore, the aim of this review was to provide an overview and comparison of the definitions of NPIs used in the current literature on older adults.

DESIGN

A systematic review was performed to provide an overview of the definitions of NPIs that are used in the current literature on older populations and to organize the characteristics involved in the definitions.

SETTING AND PARTICIPANTS

People ≥60 years of age were included, not limited to a specific setting.

METHODS

A systematic search was performed in the following 5 databases: PubMed, Embase, Clarivate Analytics/Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature, and Wiley/Cochrane Library. The time frame within the databases was from inception to December 4, 2023. Review articles, editorials and consensus papers were included.

RESULTS

We included 28 articles. We organized the definitions of NPI according to 4 different aspects: types of interventions involved, target population, goals the interventions addressed, and requirements of the interventions. Definitions in the current literature can generally be divided into 2 groups: NPIs described as not involving medication, and more elaborated multidomain definitions. Based on the results, we formulated criteria for types of interventions that can be considered an NPI.

CONCLUSIONS AND IMPLICATIONS

Using current descriptions and characteristics, elements for a new definition for NPIs were proposed. To improve research in this field, consensus needs to be reached regarding elements covered by a definition of NPIs.

Efficacy of Aromatherapy Against Behavioral and Psychological Disturbances in People With Dementia: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Behavioral and psychological symptoms of dementia (BPSD) are common in people with dementia. Aromatherapy may reduce the frequency and severity of BPSD. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of aromatherapy in relieving BPSD and improving functional ability in people with dementia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Patients with dementia receiving aromatherapy.

METHODS

A literature search was conducted using PubMed, Embase, and Cochrane Library for RCTs published before March 2024 comparing aromatherapy with control treatments in patients with dementia.

RESULTS

There were 15 trials involving 821 patients. Overall, significant reduction in BPSD was observed after 1 month of aromatherapy treatment. Among 15 trials, 9 reported the Cohen-Mansfield Agitation Inventory (CMAI) score, and 7 evaluated the Neuropsychiatric Inventory (NPI) score. The meta-analysis showed significant improvement in CMAI score [weighted mean difference (WMD) -6.31, 95% CI -9.52 to -3.11] and NPI score (WMD -8.07, 95% CI -13.53 to -2.61) in patients receiving 3 to 4 weeks of aromatherapy compared with the control group. Four of the 15 trials reported improvement in depressive mood and 3 trials reported no significant improvement in functional ability.

CONCLUSIONS AND IMPLICATIONS

In conclusion, aromatherapy is a safe and viable nonpharmacologic treatment to improve BPSD in people with dementia and its combination with massage showed higher efficacy.

Brain network correlates of affective symptoms in aMCI

Affective symptoms (i.e., depression, anxiety, and apathy) are the most prevalent subsyndrome of neuropsychiatric symptoms (NPS) in preclinical dementia, such as amnestic mild cognitive impairment (aMCI), and remain a challenge to understand and treat. The distressing nature of these symptoms and complexity of their concurrence and interaction necessitates improved understanding of their underlying neural correlates. We analyzed the relationships between functional brain topology (i.e., the way the brain's functional network is organized to allow efficient communication between regions) and affective symptoms in aMCI using cross-sectional and longitudinal methods. The analyses demonstrated that increased clustering coefficient (CC) was related to lower baseline and greater decreases in affective symptoms, while higher participation coefficient (PC) was correlated with more severe baseline affective symptoms. These findings suggest that the brain losing the capacity to form segregated functional units may be related to prevalence and severity of affective symptoms seen in aMCI.

The Sound of Memory: Investigating Music Therapy's Cognitive Benefits in Patients with Dementia-A Network Meta-Analysis of Randomized Controlled Trials

Numerous previous studies have shown the effectiveness of music therapy in enhancing cognitive functions in patients with dementia. Despite this, robust evidence in this field, especially concerning the comparison of different music therapy types, is lacking. Therefore, randomized controlled trials (RCTs) focusing on music therapy and cognitive functions in dementia patients, termed by "music" AND "dementia" OR "Alzheimer's disease" AND "cognitive", were identified from primary electronic databases to conduct this network meta-analysis (NMA). The primary outcome focused on the impact on cognitive functions, and the secondary outcome was the comparison of dropout rates between the intervention groups and the usual care control groups. Standardized mean difference (SMD) values and the corresponding 95% confidence intervals (CIs) were computed for effect evaluation. This study protocol has been registered in IPLASY (INPLASY202430082). A total of 14 RCTs with 1056 participants were enrolled, examining interventions including Active Music Therapy (AMT), Active Music Therapy with Singing (AMT + Sing), Rhythmic Music Therapy (RMT), Listening to Music (LtM), and Singing (Sing). The results indicated that RMT, AMT + Sing, and AMT all significantly improve cognitive functions in dementia patients, of which the SMD were 0.76 (95% CI = 0.32-1.21), 0.79 (95% CI = 0.03-1.49), and 0.57 (0.18-0.96), respectively. Compared with the control group (usual care), no music therapy type was associated with an increased dropout risk. In conclusion, music therapy can improve cognitive functions in patients with dementia without increasing the risk of dropout, particularly RMT, AMT + Sing, and AMT.

Supplements for cognitive ability in patients with mild cognitive impairment or Alzheimer's disease: a protocol for systematic review and network meta-analysis of randomised controlled trials

INTRODUCTION

Considering the increasing incidence of Alzheimer's disease (AD) and mild cognitive impairment (MCI) worldwide, there is an urgent need to identify efficacious, safe and convenient treatments. Numerous investigations have been conducted on the use of supplements in this domain, with oral supplementation emerging as a viable therapeutic approach for AD or MCI. Nevertheless, given the multitude of available supplements, it becomes imperative to identify the optimal treatment regimen.

METHODS AND ANALYSIS

Eight academic databases and three clinical trial registries will be searched from their inception to 1 June 2023. To identify randomised controlled trials investigating the effects of supplements on patients with AD or MCI, two independent reviewers (X-YZ and Y-QL) will extract relevant information from eligible articles, while the risk of bias in the included studies will be assessed using the Rob 2.0 tool developed by the Cochrane Collaboration. The primary outcome of interest is the overall cognitive function. Pair-wise meta-analysis will be conducted using RevMan V.5.3, while network meta-analysis will be carried out using Stata 17.0 and ADDIS 1.16.8. Heterogeneity test, data synthesis and subgroup analysis will be performed if necessary. The GRADE system will be employed to assess the quality of evidence. This study is scheduled to commence on 1 June 2023 and conclude on 1 October 2023.

ETHICS AND DISSEMINATION

Ethics approval is not required for systematic review and network meta-analysis. The results will be submitted to a peer-reviewed journal or at a conference.

TRIAL REGISTRATION NUMBER

PROSPERO (CRD42023414700).