Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli?

Music-based therapeutic interventions for people with dementia

BACKGROUND

Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music-based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music-based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music-based interventions for people with dementia.

OBJECTIVES

To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta-register-the International Clinical Trials Registry Platform on 30 November 2023.

SELECTION CRITERIA

We included randomised controlled trials of music-based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.

DATA COLLECTION AND ANALYSIS

Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random-effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE.

MAIN RESULTS

We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty-eight studies with 1366 participants contributed data to meta-analyses. Ten studies contributed data to long-term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias. For music-based therapeutic interventions compared to usual care, we found moderate-certainty evidence that, at the end of treatment, music-based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.42 to -0.04; 9 studies, 441 participants), and we found low-certainty evidence that it may have improved overall behavioural problems (SMD -0.31, 95% CI -0.60 to -0.02; 10 studies, 385 participants). We found moderate-certainty evidence that music-based therapeutic interventions likely did not improve agitation or aggression (SMD -0.05, 95% CI -0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well-being (SMD 0.14, 95% CI -0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD -0.15, 95% CI -0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI -0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI -0.02 to 0.41; 7 studies, 353 participants). Low or very-low -certainty evidence showed that music-based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes. For music-based therapeutic interventions compared to other interventions, we found low-certainty evidence that, at the end of treatment, music-based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low-certainty evidence of a positive effect on anxiety (SMD -0.75, 95% CI -1.27 to -0.24; 10 studies, 291 participants). For all other outcomes, low-certainty evidence showed no evidence of an effect: emotional well-being (SMD 0.20, 95% CI -0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD -0.14, 95% CI -0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI -0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD -0.08, 95% CI -0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI -0.21 to 0.45; 5 studies; 147 participants). We found low or very-low certainty evidence that music-based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes. Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported.

AUTHORS' CONCLUSIONS

When compared to usual care, providing people with dementia with at least five sessions of a music-based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment. When compared to other activities, music-based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low. There may be no effects on other outcomes at the end of treatment. There was no evidence of long-term effects from music-based therapeutic interventions. Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

The Impact of Enhanced Group Activity Kits (EGAKs) on Well-being of Persons With Dementia

OBJECTIVES

People living with dementia (PLwD) often feel lonely and bored. This study examined the impact of group activities on the well-being of this population when these activities were facilitated by enhanced group activity kits (EGAKs) and compared the impact of this intervention with (1) group activities not facilitated by EGAKs and (2) the absence of group activities.

DESIGN

The study was conducted as a stepped-wedge clustered trial.

SETTING AND PARTICIPANTS

The study included 123 PLwD from 6 nursing care units and 4 senior day units for PLwD in the Tel Aviv and Jerusalem metropolitan areas of Israel.

METHODS

The participants took part in group activities while their well-being was assessed using the Group Observational Measurement of Engagement (GOME) assessment tool, from which a Wellbeing Index was derived. Participants attended baseline group activities, during which a facility staff activity leader conducted activities without using EGAKs. Thereafter, the same activity leader and participants engaged in activities that used EGAKs. During the course of the study, 1 activity leader resigned, and her participants, who were no longer offered group activities, were assessed at the times during which their previous activities would have occurred.

RESULTS

Significant improvement in well-being (P < .001) was found during group activities facilitated using EGAKs compared with group activities conducted by the same activity leaders not using EGAKs. Compared with baseline group activity sessions (without EGAKs), a no-activity state yielded a highly significant decrease in well-being (P < .001).

CONCLUSIONS AND IMPLICATIONS

The results demonstrate the potential utility of EGAKs to improve the well-being of people living with dementia. This relatively inexpensive innovation can be made available on a large scale to nursing homes, assisted living facilities, and senior day centers. Future research should expand the range of content of EGAKs in order to serve PLwD of diverse cultural backgrounds.

Horticultural therapy impact on people with dementia

BACKGROUND

Dementia is a progressive disease, and as the disease progresses, many families seek help through activities and therapies. In contrast to some other therapies, horticultural therapy (HT) is widely accepted by most people with dementia (PWD) because it invites them to the natural world.

OBJECTIVES

To explore whether HT emotional and communication measures (i.e. appropriate expression of emotions, ability to communicate with others) are higher than in other activities offered to PWD in adult day care centers (ADCC) and continuing care retirement community (CCRC), and whether there is a difference between the impact of HT on the number of "positive actions" (communication actions and actions that fit the guided activity) vs. the other activities.

RESEARCH DESIGN AND METHODS

Fifty-one PWD attending ADCCs and living in one CCRC were recruited to a structured HT activity and other activities that took place in the ADCCs and CCRC. The activity took place over 10 weeks. The effects were assessed using Dementia Care Mapping (DCM) and questionnaires.

RESULTS

Paired t-tests found that higher levels of mood and behavior were observed during HT activities compared to the other activities. Also, communication and function actions were higher in the HT activities as compared to the other activities.

DISCUSSION AND IMPLICATIONS

This study adds to the growing evidence of the benefits of HT for PWD regardless of past experience in gardening/agriculture. HT seems to provide high therapeutic benefits and should be more prevalent in centers caring for PWD.

Nursing strategies for enhancing calm in older Arabs with dementia: integrating Snoezelen methods, aromatherapy, and personal items to reduce agitation

BACKGROUND

Agitation significantly impacts Arab elders with dementia. Multisensory stimulation, such as Snoezelen, shows promise but lacks exploration in Arab contexts.

OBJECTIVE

Evaluate a culturally adapted multisensory intervention-combining Snoezelen, aromatherapy, and personal items-on agitation in Arab elders with dementia.

METHODS

A quasi-experimental design assessed 31 patients receiving the intervention against 31 controls. Agitation, quality of life, and neuropsychiatric symptoms were measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI).

RESULTS

The intervention group exhibited notable reductions in CMAI scores for aggression and agitation behaviors (p < 0.001) and improvements in quality of life and NPI scores for agitation/aggression and depression/dysphoria (p < 0.001).

CONCLUSION

This culturally tailored multisensory approach effectively reduced agitation and improved well-being in Arab dementia patients. The findings advocate for further research and suggest such interventions can be beneficial in culturally diverse dementia care settings.

TRIAL REGISTRATION

ClinicalTrials.gov, ID NCT06216275.

Efficacy of COMPAs, an App Designed to Support Communication Between Persons Living With Dementia in Long-Term Care Settings and Their Caregivers: Mixed Methods Implementation Study

BACKGROUND

Persons living with dementia experience autonomy loss and require caregiver support on a daily basis. Dementia involves a gradual decline in communication skills, leading to fewer interactions and isolation for both people living with dementia and their caregivers, negatively impacting the quality of life for both members of the dyad. The resulting stress and burden on caregivers make them particularly susceptible to burnout.

OBJECTIVE

This study aims to examine the efficacy of Communication Proches Aidants (COMPAs), an app designed following the principles of person-centered and emotional communication, which is intended to improve well-being in persons living with dementia and caregivers and reduce caregiver burden.

METHODS

In this implementation study, volunteer caregivers in 2 long-term care facilities (n=17) were trained in using COMPAs and strategies to improve communication with persons living with dementia. Qualitative and quantitative analyses, semistructured interviews, and questionnaires were completed before and after 8 weeks of intervention with COMPAs.

RESULTS

Semistructured interviews revealed that all caregivers perceived a positive impact following COMPAs interventions, namely, improved quality of communication and quality of life among persons living with dementia and caregivers. Improved quality of life was also supported by a statistically significant reduction in the General Health Questionnaire-12 scores (caregivers who improved: 9/17, 53%; z=2.537; P=.01). COMPAs interventions were also associated with a statistically significant increased feeling of personal accomplishment (caregivers improved: 11/17, 65%; t15=2.430; P=.03; d=0.61 [medium effect size]).

CONCLUSIONS

COMPAs intervention improved well-being in persons living with dementia and their caregivers by developing person-centered communication within the dyad, increasing empathy, and reducing burden in caregivers although most caregivers were unfamiliar with technology. The results hold promise for COMPAs interventions in long-term care settings. Larger group-controlled studies with different populations, in different contexts, and at different stages of dementia will provide a clearer picture of the benefits of COMPAs interventions.

Ad Hoc Modifications to a High Dependency Psychiatric Unit for People With Dementia During the COVID-19 Period

The COVID-19 pandemic led to behavioral exacerbations in people with dementia. Increased hospitalizations and lack of bed availability in specialized dementia wards at a tertiary psychiatric hospital in Singapore resulted in lodging people with dementia in the High Dependency Psychiatric Unit (HDPCU). Customizations to create a dementia-friendly environment at the HDPCU included: (1) environmental modifications to facilitate orientation and engender familiarity; (2) person-centered care to promote attachment, inclusion, identity, occupation, and comfort; (3) risk management for delirium; and (4) training core competencies. Such practical solutions can also be implemented elsewhere to help overcome resource constraints and repurpose services to accommodate increasing populations of people living with dementia.

Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT)

BACKGROUND

Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings.

OBJECTIVE

The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention's feasibility in terms of acceptability, safety, and patient experience.

METHODS

A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ≥65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51%) or VR (n=34, 49%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360° VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses' daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95% significance level based on the intention-to-treat method.

RESULTS

VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy.

CONCLUSIONS

Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/22406.

The Wellbeing Index for Persons with Dementia-An Observational Study Based on the Group Observational Measurement of Engagement (GOME)

The Group Observational Measurement of Engagement (GOME) was developed to capture the impact of group recreational activities on the engagement and general wellbeing of persons with dementia. The psychometric properties of the GOME were originally described in a study of group activities conducted at one large Canadian geriatric center. Continuing this work in Israel, this article reports on further psychometric properties of the GOME based on observations of 115 persons with dementia from 10 geriatric units, of which four were senior day center units (in three institutions) and six were nursing units (representing five other institutions). Very good inter-rater reliability between research observers was found. Factor analysis suggests that the GOME's four individual-level outcomes can be combined into one indicator, the Wellbeing Index. Validity, examined via agreement between research observers and group activity leaders who were staff members in the facilities where the group activities were conducted, also showed high levels of positive correlations. The GOME provides a practical tool for assessing wellbeing in the context of group activities. It can be useful in clarifying the relative impact of process variables on participants' general wellbeing.

Economic Analysis of the Tailored Activity Program: A Nonpharmacological Approach to Improve Quality of Life in People Living With Dementia and their Caregivers

We investigated costs of delivering the Tailored Activity Program (TAP) and cost savings from two perspectives (health sector and societal) for people living with dementia (PLWD) and their caregivers (dyads) compared to attention control (AC) using data from a randomized controlled trial. The evaluation assessed intervention delivery costs and caregiver reported health care utilization. The total intervention cost of TAP was $1707/dyad versus $864/dyad for AC, and total costs over 6 months for TAP dyads as compared to AC were $1299 (CI: -$10,496, $7898) less from the healthcare perspective, and $761 (CI: -$10,133, $8611) less from the societal perspective. TAP cost savings are driven by lower use of healthcare services among participating dyads, but further analyses with larger samples is warranted to confirm its financial impact.

Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART

OBJECTIVES

Auditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia.

DESIGN

A 15-month, stepped-wedge, cluster-randomized trial. Every 3 months, a nursing home switched from care as usual to the use of the intervention.

INTERVENTION

The 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents.

SETTING AND PARTICIPANTS

We included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness.

METHODS

The primary outcome was NPS severity measured with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) by the resident's primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction).

RESULTS

The mean age of the residents (n = 97) at enrollment was 86.5 ± 6.7 years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (-8.0, 95% CI -11.7, -2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI -0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (-0.3, 95% CI -0.3, 0.8), or staff job satisfaction (-0.2, 95% CI -1.2, 0.7).

CONCLUSIONS AND IMPLICATIONS

MoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.

Frequency of changed behaviours in residential aged care and common mitigation strategies - A retrospective review of behavioural report logs

BACKGROUND

Changed behaviours in residential aged care facilities (RACF) are frequently reported in the literature. How RACF staff routinely respond to these observed changed behaviours represents a significant gap.

OBJECTIVE

To analyse the frequency of changed behaviour reported within RACF behavioural report logs and to ascertain how staff typically manage these behaviours.

METHODS

Residents (N = 25) with varying levels of cognitive function were recruited from a 160 bed RACF in Queensland, Australia. A retrospective analysis of behavioural report logs was conducted to elucidate prevalence of reported changed behaviours as categorised by RACF staff. Thematic analysis of staff recorded behavioural mitigation strategies was used to categorise staff actions. A case analysis was also conducted to highlight the challenges faced by RACF staff managing persistent acute changed behaviours using identified common mitigation strategies. The STROBE guidelines were followed for reporting.

RESULTS

There were 395 behaviours recorded in a two-month period. Physical agitation, interfering while wandering, trying to get to inappropriate places, verbal refusal of care, physical aggression, and verbal disruption were most frequently reported by staff. Management strategies included redirection, PRN psychotropic medication, reassurance, routine care practices, offering of beverages, repositioning, and rarely analgesia. A 24-h case analysis highlighted how staff utilised redirection and multiple doses of a PRN benzodiazepine with limited effectiveness.

CONCLUSION

This study reveals current mitigation strategies employed by RACF staff in response to acute changed behaviours often associated with dementia. Agitation and wandering are prevalent and are difficult for staff to manage effectively.

RELEVANCE TO CLINICAL PRACTICE

This study highlights that careful consideration should be taken to avoid overuse of PRN benzodiazepines in management of changed behaviours. Short-term mitigation strategies, such as redirection, may not be effective if underlying causes such as pain, physiological, mental, emotional, or social needs are not met.

PATIENT AND PUBLIC CONTRIBUTION

A RACF participated in project design and review.

Estimating the cost of an individualised music intervention for aged care residents with dementia

BACKGROUND

Individualised music listening has been shown to reduce agitation and improve mood in people with dementia. However, there is a paucity of research describing the cost of implementing such interventions in residential care settings for older people.

AIM

To determine the cost of implementing an individualised music intervention for older people with dementia in residential aged care in Australia.

METHOD

A simple cost analysis was undertaken to determine the cost of delivering the individualised music intervention to 32 older people with dementia at two residential aged care facilities in New South Wales. The analysis took into consideration the operating, training and delivery costs, as well as the costs of purchasing the music equipment and downloads.

RESULTS

The cost of delivering the individualised music intervention was found to be AU$6,623.76 per year - or AU$3.98 per resident per week, at 2017 values. At 2022 values, this equates to an annual cost of AU$7,130.07 (£4,031.85) for 32 residents and a weekly cost of AU$4.28 (£2.42) per resident per week.

CONCLUSION

The cost of implementing the individualised music intervention was relatively low compared with the overall cost of residential aged care for older people with dementia.

Social Health among German Nursing Home Residents with Dementia during the COVID-19 Pandemic, and the Role of Technology to Promote Social Participation

The COVID-19 pandemic severely impacted the social health of nursing home residents with dementia due to social isolation. Consequently, the frequency of Behavioral and Psychological Symptoms in Dementia (BPSD) might increase. Technological solutions might help safeguard the social health of nursing home residents with dementia. This study investigates the impacts of the COVID-19 pandemic on clinical outcomes and the availability of social activities and technology to promote social participation in nursing home residents with dementia. The study analyzed cross-sectional data from a follow-up questionnaire nested in a larger national survey of care facilities in Germany. A mixed-methods approach integrated statistical analyses of closed-ended responses and thematic analysis of free-text responses. A total of 417 valid individual responses were received, showing an overall increase in observed BPSD-with anxiety and depression most frequently occurring. Many nursing homes canceled all social activities for residents with dementia, though a few had established procedures to facilitate social participation using technology. Requirements to promote social participation in this population using technology were identified at the micro-, meso-, and macro levels. Technology requirements permeated all three levels. During and beyond the COVID-19 pandemic, technology-driven solutions to promote social health among nursing home residents with dementia should be integrated into caregiving procedures.

Activity Preferences Among Older People With Dementia Residing in Nursing Homes

The study aimed to examine the influence of personal characteristics on activity preferences using decision tree analysis and examine the effects of the variables using conventional approaches (logistic regression analysis). A descriptive study was conducted with 251 nursing home residents with dementia in Korea (76.9% female) to examine the relationship between their personal characteristics and activity preferences. Decision tree analysis was used to classify participants’ activity preferences, and preference levels were examined using logistic regression analysis. Activities were classified as either physical and social activities or cognitive and affective activities. This model showed an accuracy rate of 85.7% for positively predicting physical and social activity preference and 30.3% for positively predicting cognitive and affective activity preference. Gender was the strongest determinant of activity preference. The odds of preferring physical and social activities were 3.179 times higher among women, while the odds for preferring cognitive and affective activities were 0.412 times higher among men. Notably, cognitive and affective activity preference increased to 58.8% for married male participants. This study’s findings can contribute to the development of programs to decrease behavioral and psychological symptoms among older people with dementia residing in nursing homes and provide scientific evidence for integrating these activities into long-term services for this population.

Sounds in nursing homes and their effect on health in dementia: a systematic review

OBJECTIVES

Nursing home residents with dementia are sensitive to detrimental auditory environments. This paper presents the first literature review of empirical research investigating (1) the (perceived) intensity and sources of sounds in nursing homes, and (2) the influence of sounds on health of residents with dementia and staff.

DESIGN

A systematic review was conducted in PubMed, Web of Science and Scopus. Study quality was assessed with the Mixed Methods Appraisal Tool. We used a narrative approach to present the results.

RESULTS

We included 35 studies. Nine studies investigated sound intensity and reported high noise intensity with an average of 55-68 dB(A) (during daytime). In four studies about sound sources, human voices and electronic devices were the most dominant sources. Five cross-sectional studies focused on music interventions and reported positives effects on agitated behaviors. Four randomized controlled trials tested noise reduction as part of an intervention. In two studies, high-intensity sounds were associated with decreased nighttime sleep and increased agitation. The third study found an association between music and less agitation compared to other stimuli. The fourth study did not find an effect of noise on agitation. Two studies reported that a noisy environment had negative effects on staff.

CONCLUSIONS

The need for appropriate auditory environments that are responsive to residents' cognitive abilities and functioning is not yet recognized widely. Future research needs to place greater emphasis on intervention-based and longitudinal study design.

Management of Agitation in Dementia and Effects on Inpatient Length of Stay

Background

Agitation associated with dementia impacts delivery of medical care and is a major reason for institutionalization in dementia patients. This study examines the association of medication use and other clinical factors with patients' 'dischargeability' (i.e., amount of time until a patient is considered dischargeable from an inpatient unit).

Methods

This study was a retrospective chart review examining 200 patients with dementia and agitation, hospitalized at a Canadian acute care geriatric ward between November 2007 and November 2018. The main outcome measure was time until a patient was deemed dischargeable. Univariate linear regression analyses, followed by multiple linear regression analyses, were used.

Results

Risperidone and quetiapine were the most commonly prescribed medications, but were not associated with time until dischargeable. Olanzapine (40.9 vs. 16.2 days until dischargeable, β = 0.23, p = .001), regular benzodiazepine (32.7 vs. 16.5 days until dischargeable, β = 0.15, p = .027), and as-needed ('PRN') benzodiazepine use (31.7 vs. 15.9 days until dischargeable, β =0.19, p = .006) were independently associated with prolonging time until dischargeable.

Conclusions

Olanzapine, benzodiazepine, and PRN benzodiazepine use were associated with longer time until patients with dementia and agitation were considered ready for discharge. This raises the question as to whether the risks of these medications outweigh the benefits in a hospital setting.

Importance of Distinguishing Reactive and Proactive Aggression in Dementia Care

Aggressive behavior is one of the most disturbing symptoms of Alzheimer disease and other progressive neurodegenerative dementias. Development of strategies for management of aggressive behaviors in people with dementia is hindered by a lack of recognition that aggression is not a uniform behavioral construct. It is possible to distinguish 2 types of aggression: reactive or impulsive aggression and proactive or premeditated aggression. Research concerning aggressive behaviors in people with dementia is hindered by scales describing behavioral symptoms of dementia which do not distinguish between reactive and proactive aggressions because they do not consider the factors leading to these behaviors. Reactive aggression is caused by lack of understanding, leading to rejection of care, while proactive aggression could be caused by a psychopathic personality, hallucinations or delusions, and other determinants. It is difficult to underestimate the importance of distinguishing reactive and proactive aggressions in people with dementia because there are different strategies that can be used for management of these behaviors. For reactive aggression, delayed treatment, distraction, improved communication, and change in treatment strategy is useful, while antipsychotic medication may be needed for treatment of proactive aggression. Dementia is increasing the risk of both types of aggressions and antidepressant treatment can be helpful. Most importantly, persons exhibiting reactive aggression should not be labeled "aggressors" because this behavior could be caused by unmet persons' needs, pain and poor communication with care providers.

Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions

Agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. According to several observations, agitation prevalence ranges from 30 to 50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia (VaD). With an overall prevalence of about 30%, agitation is the third most common neuropsychiatric symptoms (NPS) in dementia, after apathy and depression, and it is even more frequent (80%) in residents of nursing homes. The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC), respectively, meaningful in selecting the salient stimuli and subsequent decision-making and behavioral reactions. Furthermore, increased sensitivity to noradrenergic signaling has been observed, possibly due to a frontal lobe up-regulation of adrenergic receptors, as a reaction to the depletion of noradrenergic neurons within the locus coeruleus (LC). Indeed, LC neurons mainly project toward the OFC and ACC. These observations may explain the abnormal reactivity to weak stimuli and the global arousal found in many patients who have dementia. Furthermore, agitation can be precipitated by several factors, e.g., the sunset or low lighted environments as in the sundown syndrome, hospitalization, the admission to nursing residencies, or changes in pharmacological regimens. In recent days, the global pandemic has increased agitation incidence among dementia patients and generated higher distress levels in patients and caregivers. Hence, given the increasing presence of this condition and its related burden on society and the health system, the present point of view aims at providing an extensive guide to facilitate the identification, prevention, and management of acute and chronic agitation in dementia patients.

Group Activity Participation in Relation to Contextual Isolation of United States Nursing Home Residents Living with Alzheimer's Disease and Related Dementias

Background

Residents of nursing homes frequently report loneliness and isolation, despite being in an environment shared with other residents and staff.

Objective

To describe, among long-stay US nursing home residents living with Alzheimer's disease and/or related dementias (ADRD), group activity participation in relation to contextual isolation: living in a nursing home where fewer than 20% of residents share socially salient characteristic(s).

Design

A cross-sectional evaluation of group activity participation in relation to contextual isolation across 20 characteristics based on demographic characteristics, habits and interests, and clinical and care dimensions.

Setting

US nursing homes.

Participants

We included 335,421 residents with ADRD aged ≥50 years with a Minimum Data Set 3.0 annual assessment in 2016 reporting their preference for group activity participation, and 94,735 with participation observed by staff.

Measurements

We identified 827,823 annual (any anniversary) assessments performed on nursing home residents in 2016, selecting one at random for each resident, after prioritizing the assessment with the least missing data (n=795,038). MDS 3.0 item F0500e assesses resident interest in group activities.

Results

When considering all potential sources of contextual isolation considered, 30.7% were contextually isolated on the basis of a single characteristic and 13.7% were contextually isolated on the basis of two or more characteristics. Among residents reporting importance of group activity, 81% of those not contextually isolated reported that group activity participation was important, as did 78% of those isolated on one characteristic, and 75% of those isolated on multiple characteristics. Among residents with staff-observed group activity participation, 64% of those not contextually isolated reported were observed participating in group activities, as were 59% of those isolated on one characteristic, and 52% of those isolated on multiple characteristics.

Conclusion

Residents with ADRD facing contextual isolation placed less importance on group activity than residents who were not contextually isolated.

Letter to the Editor: COVID-19 and Persons with Dementia in Acute Care Settings: How to "EVADE" Challenging Behaviors

The double whammy of dementia and coronavirus disease 2019 (COVID-19) has raised huge concerns for healthcare systems which are already struggling to cope with care demands of persons with dementia (PWD) in non-pandemic times (1). PWD who are admitted to acute care services are particularly vulnerable to behavioural changes and adverse outcomes from delirium (2, 3). During the COVID-19 period, ward relocation is frequently encountered due to COVID-19 screening and segregation; this constant changing of environment and care teams puts PWD at risk of behavioural exacerbations. This is aggravated by restrictive visitor policies in hospitals, depriving PWD of the reassuring presence of family members. Not surprisingly, caring for persons with dementia (PWD) with behavioral issues in acute care settings has become extremely challenging.

Using Normalization Process Theory to Evaluate the Implementation of Montessori-Based Volunteer Visits Within a Canadian Long-Term Care Home

BACKGROUND AND OBJECTIVES

Montessori-based interventions (MBIs) have potential to improve the life quality of long-term care residents with dementia. In this study, we aimed to understand the processes by which staff integrated a volunteer-led MBI into practice within a special dementia care unit, and to explore staff members ' perceptions of associated strengths and limitations.

RESEARCH DESIGN AND METHODS

This study relied on a qualitative descriptive design. Following a 3-month period of volunteer involvement, we conducted 21 interviews with staff members to document perceptions of the new program and subjected interview transcripts to qualitative content analysis, guided by normalization process theory.

RESULTS

During the implementation of the volunteer-led MBI, staff members developed a shared understanding of the intervention, a sense of commitment, practical ways to support the intervention, and opinions about the value of the residents. Overall, we found that the volunteer-led MBI was quickly and successfully integrated into practice and was perceived to support both residents and staff members in meaningful ways. Nevertheless, some limitations were also identified.

DISCUSSION AND IMPLICATIONS

Volunteer-delivered MBIs are a useful adjunct to practice within a special dementia care unit. This article raises attention to some strengths and limitations associated with this approach.

Sensory-Based Interventions for Adults with Dementia and Alzheimer's Disease: A Scoping Review

The purpose of this review was to explore the effectiveness of sensory-based interventions for clients with dementia and Alzheimer's disease living in residential facilities. Nine databases and key sources were searched from 2002 to September 2017. Forty-seven articles met the inclusion criteria. There was strong evidence for use of massage. There was moderate evidence for occupationally and environmentally based multisensory activities including light, gardening, mealtime, music, Montessori, animal assisted therapy, dance, and yoga interventions. There was inconclusive evidence for aromatherapy, art, Snoezelen rooms, and combined visual and auditory interventions. Future research should focus on defining protocols for efficacious interventions.

Improving mental health and reducing antipsychotic use in people with dementia in care homes: the WHELD research programme including two RCTs

Background

The effective management of agitation and other neuropsychiatric and behavioural symptoms in people with dementia is a major challenge, particularly in care home settings, where dementia severity is higher and there is limited training and support for care staff. There is evidence for the value of staff training and the use of psychosocial approaches; however, no intervention currently exists that combines these elements into an intervention that is fit for purpose and effective in these settings based on evidence from a randomised controlled trial.

Objective

The objective was to develop and evaluate a complex intervention to improve well-being, reduce antipsychotic use and improve quality of life in people with dementia in care homes through person-centred care, management of agitation and non-drug approaches.

Design

This was a 5-year programme that consisted of six work packages. Work package 1 consisted of two systematic reviews of personalised psychosocial interventions for behavioural and psychological symptoms for people with dementia in care homes. Work package 2 consisted of a metasynthesis of studies examining implementation of psychosocial interventions, in addition to developing a draft Well-being and Health for people with Dementia (WHELD) programme. Work package 3 consisted of a factorial study of elements of the draft WHELD programme in 16 care homes. Work package 4 involved optimisation of the WHELD programme based on work package 3 data. Work package 5 involved a multicentre randomised controlled trial in 69 care homes, which evaluated the impact of the optimised WHELD programme on quality of life, agitation and overall neuropsychiatric symptoms in people with dementia. Work package 6 focused on dissemination of the programme.

Setting

This programme was carried out in care homes in the UK.

Participants

Participants of this programme were people with dementia living in care homes, and the health and care professionals providing treatment and care in these settings.

Results

Work package 1: reviews identified randomised controlled trials and qualitative evidence supporting the use of psychosocial approaches to manage behavioural symptoms, but highlighted a concerning lack of evidence-based training manuals in current use. Work package 2: the meta-analysis identified key issues in promoting the use of interventions in care homes. The WHELD programme was developed through adaptation of published approaches. Work package 3: the factorial trial showed that antipsychotic review alone significantly reduced antipsychotic use by 50% (odds ratio 0.17, 95% confidence interval 0.05 to 0.60). Antipsychotic review plus social interaction significantly reduced mortality (odds ratio 0.36, 95% confidence interval 0.23 to 0.57), but this group showed significantly worse outcomes in behavioural and psychological symptoms of dementia than the group receiving neither antipsychotic review nor social interaction (mean difference 7.37 symptoms, 95% confidence interval 1.53 to 13.22 symptoms). This detrimental impact was reduced when combined with social interaction (mean difference –0.44 points, 95% confidence interval –4.39 to 3.52 points), but with no significant benefits for agitation. The exercise intervention significantly improved neuropsychiatric symptoms (mean difference –3.58 symptoms, 95% confidence interval –7.08 to –0.09 symptoms) but not depression (mean difference –1.21 points, 95% confidence interval –4.35 to 1.93 points). Qualitative work with care staff provided additional insights into the acceptability and feasibility of the intervention. Work package 4: optimisation of the WHELD programme led to a final version that combined person-centred care training with social interaction and pleasant activities. The intervention was adapted for delivery through a ‘champion’ model. Work package 5: a large-scale, multicentre randomised controlled trial in 69 care homes showed significant benefit to quality of life, agitation and overall neuropsychiatric symptoms, at reduced overall cost compared with treatment as usual. The intervention conferred a statistically significant improvement in quality of life (Dementia Quality of Life Scale – Proxy z-score of 2.82, mean difference 2.54, standard error of measurement 0.88, 95% confidence interval 0.81 to 4.28, Cohen’s d effect size of 0.24; p = 0.0042). There were also statistically significant benefits in agitation (Cohen-Mansfield Agitation Inventory z-score of 2.68, mean difference –4.27, standard error of measurement 1.59, 95% confidence interval –7.39 to –1.15, Cohen’s d effect size of 0.23; p = 0.0076) and overall neuropsychiatric symptoms (Neuropsychiatric Inventory – Nursing Home version z-score of 3.52, mean difference –4.55, standard error of measurement 1.28, 95% confidence interval –7.07 to –2.02, Cohen’s d of 0.30; p < 0.001). The WHELD programme contributed to significantly lower health and social care costs than treatment as usual (cost difference –£4740, 95% confidence interval –£6129 to –£3156). Focus groups were conducted with 47 staff up to 12 months after the end of work package 5, which demonstrated sustained benefits. Work package 6: the outputs of the programme were translated into general practitioner workshops and a British Medical Journal e-learning module, an updated national best practice guideline and a portfolio of lay and care home outreach activities.

Limitations

Residents with dementia were not involved in the qualitative work.

Conclusions

The WHELD programme is effective in improving quality of life and reducing both agitation and overall neuropsychiatric symptoms in people with dementia in care homes. It provides a structured training and support intervention for care staff, with lower overall costs for resident care than treatment as usual.

Future work

It will be important to consider the long-term sustainability of the WHELD programme and cost-effective means of long-term implementation.

Trial registration

Current Controlled Trials ISRCTN40313497 and ISRCTN62237498.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

A review of measures of three common dementia-related behaviors: Rejection of care, aggression, and agitation

BACKGROUND

Clustering of behavioral symptoms in dementia is common in dementia scales. However, lack of distinction may have negative treatment implications when a treatment response differs depending on classification of behaviors. Historically, rejection of care, aggression, and agitation have been lumped together. Yet, several studies have indicated these may be conceptually different behaviors.

OBJECTIVE

To examine how rejection of care, aggression, and agitation are described and operationalized in existing measures of dementia-related behaviors.

METHOD

We identified instruments developed to measure behavioral symptoms of dementia from two existing systematic reviews. Additionally, we conducted a literature review of peer-reviewed articles published from 1980 to 2017 to identify measures that were not captured in the two previous reviews.

RESULTS

43 instruments developed to measure behavioral symptoms of dementia were examined. Of these, 25 (58.1%) included items related to rejection of care; 32 (74.4%) included items related to aggression; and 35 (81.4%) included agitation items. Descriptions of these behaviors were highly variable across the instruments.

CONCLUSIONS

The review demonstrated that rejection, aggression, and agitation are measured in most scales, yet their operationalization is highly variable, and they are not typically distinguished from each other. Future efforts should be directed at developing uniform terminology to describe dementia-related behaviors while distinguishing rejection of care, aggression, and agitation in dementia scales.

Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT

BACKGROUND

The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required.

OBJECTIVE

To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care.

DESIGN

A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors.

SETTING

Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub.

PARTICIPANTS

Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation.

INTERVENTION

Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert.

MAIN OUTCOME MEASURES

The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life.

RESULTS

There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified.

LIMITATIONS

The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important.

CONCLUSIONS

There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes.

FUTURE WORK

Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82288852.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

The impact of environmental factors on persons with dementia attending recreational groups

OBJECTIVES

The Comprehensive Process Model of Group Engagement posits that personal factors (eg, cognitive function), stimulus factors (eg, group activity content and group size), and environmental factors (eg, light and noise) impact the response to group activities. This paper reports the impact of environmental and group characteristics on engagement, mood, and sleepiness of persons with dementia attending group activities.

METHODS/DESIGN

The sample included 69 nursing home residents. Environmental contexts of activities included time of day, location, noise, light, and temperature. Outcome variables captured engagement, mood, and sleepiness, observed during 20 group activity sessions. Mixed model analyses were used to examine the impact of environmental and group attributes on the outcome variables.

RESULTS

Background noise and time of day significantly affected outcome variables after controlling for participants' cognitive functioning and group topic. Background noise was related with decreased engagement and increased sleepiness. Activities conducted before noon were associated with increased sleepiness. Group size did not affect the outcome variables. There was little variation concerning temperature and light.

CONCLUSIONS

These findings have implications for architectural and ongoing planning. The methodology presents a model for continuous quality improvement. The main components of the Comprehensive Process Model of Group Engagement significantly impacted group activity engagement.

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

BACKGROUND

People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision.

OBJECTIVES

To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes.

DESIGN

The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible.

SETTING

Nursing homes in England providing care for people with dementia.

PARTICIPANTS

Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff.

INTERVENTION

Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement.

MAIN OUTCOME MEASURES

The two contender primary outcome measures were Comfort Assessment in Dying - End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data - health economic outcomes, medication/service use and intervention activity.

RESULTS

Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported.

CONCLUSIONS

A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification.

FUTURE WORK

In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14948133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.

Clinical Aspects of Neurobehavioral Symptoms of Dementia

Neurobehavioral symptoms of dementia (NBSD) are very common and are significant symptoms of the illness, contributing most to caregiver burdens and often resulting in premature institutionalization of the person with dementia. The main symptoms of NBSD are anxiety, depression, delusions, and hallucinations. NBSD produce significant problems for both patients and caregivers. The pathophysiology of NBSD is determined by genetic, structural, or environmental factors. Therefore, treatment of NBSD requires continuous and organic cooperation between patients, caregivers, social environments, and doctors. Therefore, it is important for neurologists, who mainly view NBSD for dementia patients, to increase their understanding of these more comprehensive areas as well as the latest insights and treatments to help patients and caregivers.

Challenges in Collecting Big Data in A Clinical Environment with Vulnerable Population: Lessons Learned from A Study Using A Multi-modal Sensors Platform

Agitation is one of the most common behavioural and psychological symptoms in people living with dementia (PLwD). This behaviour can cause tremendous stress and anxiety on family caregivers and healthcare providers. Direct observation of PLwD is the traditional way to measure episodes of agitation. However, this method is subjective, bias-prone and timeconsuming. Importantly, it does not predict the onset of the agitation. Therefore, there is a need to develop a continuous monitoring system that can detect and/or predict the onset of agitation. In this study, a multi-modal sensor platform with video cameras, motion and door sensors, wristbands and pressure mats were set up in a hospital-based dementia behavioural care unit to develop a predictive system to identify the onset of agitation. The research team faced several barriers in the development and initiation of the study, namely addressing concerns about the study ethics, logistics and costs of study activities, device design for PLwD and limitations of its use in the hospital. In this paper, the strategies and methodologies that were implemented to address these challenges are discussed for consideration by future researchers who will conduct similar studies in a hospital setting.

Effects of the Tailored Activity Program in Brazil (TAP-BR) for Persons With Dementia: A Randomized Pilot Trial

OBJECTIVES

The objectives of this study were to evaluate the effects of the Tailored Activity Program-Brazilian version (TAP-BR), on behavioral symptoms and the quality of life (QOL) in persons with dementia, as well as on their caregivers, and on caregiver burden.

MATERIALS AND METHODS

A 2-group randomized controlled trial with 30 dyads was conducted: the experimental group (n=15) received TAP-BR over 4 months, and a wait-list control group (n=15) received usual care. Dyads were recruited from the community of Santos City, Brazil.

RESULTS

For persons with dementia, 50% were female individuals, the average age was 81.37 (±7.57), and the educational level was 9.97 (±5.32) years. For caregivers, 83.33% were female, the average age was 65.97 (±10.13), and the educational level was 12.10 (±4.44) years. At posttest, in comparison with the wait-list control group, experimental group caregivers reported greater reductions in number (P<0.001; Cohen d=0.93), frequency (P<0.001; Cohen d=1.12), and intensity (P<0.001; Cohen d=0.77) of the behavioral psychological symptoms of dementia, and caregiver distress (P<0.001; Cohen d=0.87). Caregivers also reported improvement in their own QOL (P<0.05; Cohen d=0.57) and that of the person with dementia (P<0.01; Cohen d=0.56); no differences were found in the ratings of QOL by the person with dementia themselves.

CONCLUSIONS

The results provide compelling evidence that the TAP-BR is an effective strategy to support dementia caregivers in other cultures (cross-validation).

Effectiveness of DementiAbility Methods: The Montessori Way on agitation in long-term care home residents with dementia in Hong Kong

OBJECTIVE

To investigate the effect of the DementiAbility Methods: The Montessori Way (DMMW) on agitation in long-term care home residents with dementia. The activities using the DMMW are hypothesized to reduce agitation in terms of its frequency and disruptiveness to greater extent than structured social activities as control.

METHODS

Forty-six long-term care home residents with dementia were randomly allocated to receive the DMMW (n = 23) or structured social activities as control (n = 23). Each participant received six intervention sessions of 45 minutes each within 2 weeks, at long-term care home. Agitation in terms of frequency and disruptiveness before and after the intervention were compared.

RESULTS

The results showed that the DMMW resulted in significant reduction in overall frequency and disruptiveness of agitation. The DMMW group had significant reduction in frequency and disruptiveness of verbal aggressive, physical nonaggressive, and physical aggressive behaviors after the intervention.

CONCLUSIONS

The present findings support the potential of the DMMW as a safe and efficacious therapeutic intervention for addressing agitation in long-term care home residents with dementia, relevant to Hong Kong culture.

Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions

BACKGROUND

Seventy percent of people with advanced dementia live and die in care homes. Multisensory approaches, such as Namaste Care, have been developed to improve the quality of life and dying for people with advanced dementia but little is known about effectiveness or optimum delivery. The aim of this review was to develop an explanatory account of how the Namaste Care intervention might work, on what outcomes, and in what circumstances.

METHODS

This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories, and their validation with a purposive sample of stakeholders. Twenty stakeholders - user/patient representatives, dementia care providers, care home staff, researchers -took part in interviews and/or workshops.

RESULTS

We included 85 papers. Eight focused on Namaste Care and the remainder on other types of sensory interventions such as music therapy or massage. We identified three context-mechanism-outcome configurations which together provide an explanatory account of what needs to be in place for Namaste Care to work for people living with advanced dementia. This includes: providing structured access to social and physical stimulation, equipping care home staff to cope effectively with complex behaviours and variable responses, and providing a framework for person-centred care. A key overarching theme concerned the importance of activities that enabled the development of moments of connection for people with advanced dementia.

CONCLUSIONS

This realist review provides a coherent account of how Namaste Care, and other multisensory interventions might work. It provides practitioners and researchers with a framework to judge the feasibility and likely success of Namaste Care in long term settings. Key for staff and residents is that the intervention triggers feelings of familiarity, reassurance, engagement and connection.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016047512.

Emerging treatments for the behavioral and psychological symptoms of dementia

Dementia is referred to a loss of memory and decline in other mental abilities at levels critical enough to hinder performance of daily activities. It can be of several types, depending on the underlying pathophysiology. The behavioral and psychological symptoms of dementia (BPSD) are various, but the most clinically significant are depression, apathy, and anxiety. Other BPSD include agitation, aberrant motor behavior, elation, hallucinations, and alterations in sleep and appetite. About 90% of sufferers of dementia are affected by BPSD during the course of the illness. These symptoms occur in demented patients irrespective of the dementia subtype. However, there has not been significant development in the areas of disease-modifying pharmacotherapeutics for dementia. Therefore, tackling BPSD has emerged as a research avenue in the recent past. Existing antidepressants, antipsychotics, and cholinergic agents have been extensively used in the treatment of BPSD, independently and in different combinations. However, these agents have not successful in completely alleviating such symptoms. Research in this field is going on globally, but it is still limited by various factors. There is a strong need to develop new entities and test them clinically. This review focuses on emerging treatments for the management of clinically significant BPSD.

Alzheimer's disease: some pharmacological and non-pharmacological approaches to correcting neuropsychiatric disorders

Today, there is no reliable pharmacological correction of dementia, despite its high prevalence worldwide. The clinical presentation of Alzheimer's disease at one or another stage is accompanied by neuropsychiatric disorders (NPDs) in addition to cognitive defect. The intensity and range of NPDs are different. The possibilities of drug therapy for NPDs are demonstrated. The role of akatinol memantine in correcting a number of psychological and behavioral disorders is highlighted. Biological, psychological, social, and environmental factors are identified among those that contribute to or provoke the development of NPDs. Knowledge of the triggers of mental disorders makes it possible to prevent and thereby reduce or eliminate NPDs. Special emphasis is laid on the patient-caregiver relationship. In recent years, non-pharmacological interventions have been increasingly used as priority-line therapy for NPDs. There are data on main methods for non-pharmacological correction and on the efficiency of their application.

Music-based therapeutic interventions for people with dementia

BACKGROUND

Dementia is a clinical syndrome with a number of different causes which is characterised by deterioration in cognitive, behavioural, social and emotional functions. Pharmacological interventions are available but have limited effect to treat many of the syndrome's features. Less research has been directed towards non-pharmacological treatments. In this review, we examined the evidence for effects of music-based interventions.

OBJECTIVES

To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour and cognition at the end of therapy and four or more weeks after the end of treatment.

SEARCH METHODS

We searched ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 19 June 2017 using the terms: music therapy, music, singing, sing, auditory stimulation. Additional searches were carried out on 19 June 2017 in the major healthcare databases MEDLINE, Embase, PsycINFO, CINAHL and LILACS; and in trial registers and grey literature sources.

SELECTION CRITERIA

We included randomised controlled trials of music-based therapeutic interventions (at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.

DATA COLLECTION AND ANALYSIS

Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data and assess methodological quality of the included studies. If necessary, we contacted trial authors to ask for additional data, including relevant subscales, or for other missing information. We pooled data using random-effects models.

MAIN RESULTS

We included 22 studies with 1097 randomised participants. Twenty-one studies with 890 participants contributed data to meta-analyses. Participants in the studies had dementia of varying degrees of severity, and all were resident in institutions. Seven studies delivered an individual music intervention; the other studies delivered the intervention to groups of participants. Most interventions involved both active and receptive musical elements. The methodological quality of the studies varied. All were at high risk of performance bias and some were at high risk of detection or other bias.At the end of treatment, we found low-quality evidence that the interventions may improve emotional well-being and quality of life (standardised mean difference (SMD) 0.32, 95% confidence interval (CI) 0.02 to 0.62; 9 studies, 348 participants) and reduce anxiety (SMD -0.43, 95% CI -0.72 to -0.14; 13 studies, 478 participants). We found low-quality evidence that music-based therapeutic interventions may have little or no effect on cognition (SMD 0.15, 95% CI -0.06 to 0.36; 7 studies, 350 participants). There was moderate-quality evidence that the interventions reduce depressive symptoms (SMD -0.27, 95% CI -0.45 to -0.09; 11 studies, 503 participants) and overall behaviour problems (SMD -0.23, 95% CI -0.46 to -0.01; 10 studies, 442 participants), but do not decrease agitation or aggression (SMD -0.07, 95% CI -0.24 to 0.10; 14 studies, 626 participants). The quality of the evidence on social behaviour was very low, so effects were very uncertain.The evidence for long-term outcomes measured four or more weeks after the end of treatment was of very low quality for anxiety and social behaviour, and for the other outcomes, it was of low quality for little or no effect (with small SMDs, between 0.03 and 0.34).

AUTHORS' CONCLUSIONS

Providing people with dementia who are in institutional care with at least five sessions of a music-based therapeutic intervention probably reduces depressive symptoms and improves overall behavioural problems at the end of treatment. It may also improve emotional well-being and quality of life and reduce anxiety, but may have little or no effect on agitation or aggression or on cognition. We are uncertain about effects on social behaviour and about long-term effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

Targeting Behavioral Symptoms and Functional Decline in Dementia: A Randomized Clinical Trial

BACKGROUND/OBJECTIVES

Dementia-related behavioral symptoms and functional dependence result in poor quality of life for persons with dementia and their caregivers. The goal was to determine whether a home-based activity program (Tailored Activity Program; TAP-VA) would reduce behavioral symptoms and functional dependence of veterans with dementia and caregiver burden.

DESIGN

Single-blind (interviewer), parallel, randomized, controlled trial (Clinicaltrials.gov: NCT01357564).

SETTING

Veteran's homes.

PARTICIPANTS

Veterans with dementia and their family caregivers (N = 160 dyads).

INTERVENTION

Dyads in TAP-VA underwent 8 sessions with occupational therapists to customize activities to the interests and abilities of the veterans and educate their caregivers about dementia and use of customized activity. Caregivers assigned to attention control received up to 8 telephone-based dementia education sessions with a research team member.

MEASUREMENTS

Primary outcomes included number of behaviors and frequency of their occurrence multiplied by severity of occurrence; secondary outcomes were functional dependence, pain, emotional well-being, caregiver burden (time spent caregiving, upset with behaviors) and affect at 4 (primary endpoint) and 8 months.

RESULTS

Of 160 dyads (n = 76 TAP-VA; n = 84 control), 111 completed 4-month interviews (n = 51 TAP-VA; n = 60 control), and 103 completed 8-month interviews (n = 50 TAP-VA; n = 53 control). At 4 months, compared to controls, the TAP-VA group showed reductions in number (difference in mean change from baseline = -0.68, 95% CI = -1.23 to -0.13) and frequency by severity (-24.3, 95% CI = -45.6 to -3.1) of behavioral symptoms, number of activities needing assistance with (-0.80, 95% CI = -1.41 to -0.20), functional dependence level (4.09, 95% CI = 1.06, 7.13), and pain (-1.18, 95% CI = -2.10 to -0.26). Caregivers of veterans in TAP-VA reported less behavior-related distress. Benefits did not extend to 8 months.

CONCLUSION

TAP-VA had positive immediate effects and no adverse events. Because TAP-VA reduces behavioral symptoms, slows functional dependence, and alleviates pain and caregiver distress, it is a viable treatment option for families.

Activity Preferences of persons with dementia: An examination of reports by formal and informal caregivers

Objectives

The aims of this study are (1) to describe the types of leisure activities preferred by persons with dementia in the past and present, as reported by family members and therapeutic recreation staff members, and (2) to examine the influence of demographic and functional abilities variables on the perceived current interest of persons with dementia.

Method

Family members of persons with dementia and therapeutic recreation staff involved in the care of those persons completed an activities preference assessment concerning the persons with dementia. Participants were recruited from a nursing home and a senior day center. Family members completed the assessment for the past and present, and staff members completed the assessment for the present.

Results

For present preferences, music was the most often preferred activity according to both family and staff, followed by reminiscence and reading, while the least desirable activity was cooking/baking according to family and trivia games according to the staff. Current preferences were significantly related to past preferences. Gender was also related to preference for some activities. A significant reduction in preference from the premorbid past to the present was found for music, reading, and cooking. Additionally, the number of activities persons preferred as reported by both caregiver groups was affected by dementia. Family members tended to report lower preference levels for the activities in the present in comparison to the staff, and they were also more likely to report not knowing the present level of preference than therapeutic recreation staff members.

Conclusion

The assessments by both therapeutic recreation staff members and family members shed light on leisure preferences of persons with dementia, while the varying reports reflect a possibly different perspective of the two caregiver groups.

Activity groups for persons with dementia: Personal predictors of participation, engagement and mood

This study examined the relationship between personal characteristics and attendance, engagement, sleep, and mood outcomes of persons with dementia participating in group activities. The purpose of this study is to examine which persons with dementia benefit most from group interventions. Sixty-nine persons with dementia were observed by research and therapeutic recreation staff during 10 types of group activities (reading aloud with discussion, choral-singing, baking, creative storytelling, brain games, active games, exercise, reminiscence poetry, holiday newsletter, and holiday discussions) on multiple outcomes (attendance duration, sleep, engagement, active participation, attitude, and positive mood). Correlations between these outcomes and personal characteristics (demographics, functional and medical characteristics, personal preferences for group activities) were conducted. Variables with significant correlations were then entered into regression analyses. Many of the personal characteristics were significantly correlated with the outcomes. Cognitive function was the most consistent predictor of all outcomes. Personal characteristics, particularly cognitive function, can predict the responses of persons with dementia during group activities.

Measurement of agitation and aggression in adult and aged neuropsychiatric patients: review of definitions and frequently used measurement scales

Agitation and aggression in adult psychiatric patients with psychoses and in persons with dementia increase the burden of disease and frequently cause hospitalization. The implementation of currently available management strategies and the development of new ones is hindered by inconsistent terminology that confuses agitation with aggression. This confusion is maintained by many rating scales that fail to distinguish between these two syndromes. We review the frequently used rating scales with a particular focus on their ability to separate agitation from aggression. Agitation and aggression are two different syndromes. For example, reactive aggression is often precipitated by rejection of care and may not be associated with agitation per se. We propose, in treatment studies of behavioral symptoms of dementia and challenging behaviors in psychoses, that outcomes should be evaluated separately for agitation and aggression. This is important for investigation of drug effectiveness since the medication may be effective against one syndrome but not the other. Separate assessments of agitation and aggression should be a general principle of trial design with particular salience for registration studies of medications proposed for approval by the U.S. Food and Drug Administration and other regulatory bodies.

Feasibility of the Tailored Activity Program for Hospitalized (TAP-H) Patients With Behavioral Symptoms

PURPOSE OF THE STUDY

To evaluate feasibility of implementing the Tailored Activity Program for Hospitals (TAP-H) to improve engagement in patients with dementia admitted for behavioral disturbances.

DESIGN AND METHODS

TAP-H involves up to 11 in-hospital sessions to develop activities tailored to patient interests and capabilities and train staff/families in their use. Interventionists (occupational therapists) recorded session lengths, patient engagement (N = 20), and staff (N = 4) readiness to use activities. Family interviews (N = 20) identified patient behaviors at admission and satisfaction with TAP-H 1 month postdischarge. A time series design with multiple behavioral observations (63 videotaped sessions) compared affective, verbal, and nonverbal behavioral responses in a standardized activity (baseline) to treatment sessions.

RESULTS

Average number of treatment sessions per patient was 8.00 (SD = 2.71, range 3-13). Average time spent per session was 38.18min (SD = 10.01, range 19.09-57.50). Interventionists observed high patient engagement across treatment sessions. Observational data revealed increases in pleasure and positive gestures and decreases in anxiety/anger, negative verbalizations, and negative nonverbal behaviors from baseline to intervention sessions. Staff improved in readiness and families expressed high program satisfaction with 59.4% of activities used at home.

IMPLICATIONS

TAP-H represents a unique collaborative care model that integrates facility-based staff in the behavioral treatment of patients with dementia and results in improved affect and reduced negative behaviors. TAP-H can be incorporated into routine hospital care and payment mechanisms. Future efforts should evaluate its effectiveness in reducing inappropriate pharmacologic use and strategies to enhance continued activity use by staff during hospitalization and families following discharge.

Music-based therapeutic interventions for people with dementia

BACKGROUND

Dementia is a clinical syndrome with a number of different causes which is characterised by deterioration in cognitive, behavioural, social and emotional functions. Pharmacological interventions are available but have limited effect to treat many of the syndrome's features. Less research has been directed towards non-pharmacological treatments. In this review, we examined the evidence for effects of music-based interventions as a treatment.

OBJECTIVES

To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour, and cognition at the end of therapy and four or more weeks after the end of treatment.

SEARCH METHODS

We searched ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 14 April 2010 using the terms: music therapy, music, singing, sing, auditory stimulation. Additional searches were also carried out on 3 July 2015 in the major healthcare databases MEDLINE, Embase, psycINFO, CINAHL and LILACS; and in trial registers and grey literature sources. On 12 April 2016, we searched the major databases for new studies for future evaluation.

SELECTION CRITERIA

We included randomized controlled trials of music-based therapeutic interventions (at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities.

DATA COLLECTION AND ANALYSIS

Two reviewers worked independently to screen the retrieved studies against the inclusion criteria and then to extract data and assess methodological quality of the included studies. If necessary, we contacted trial authors to ask for additional data, including relevant subscales, or for other missing information. We pooled data using random-effects models.

MAIN RESULTS

We included 17 studies. Sixteen studies with a total of 620 participants contributed data to meta-analyses. Participants in the studies had dementia of varying degrees of severity, but all were resident in institutions. Five studies delivered an individual music intervention; in the others, the intervention was delivered to groups of participants. Most interventions involved both active and receptive musical elements. The methodological quality of the studies varied. All were at high risk of performance bias and some were at high risk of detection or other bias. At the end of treatment, we found low-quality evidence that music-based therapeutic interventions may have little or no effect on emotional well-being and quality of life (standardized mean difference, SMD 0.32, 95% CI -0.08 to 0.71; 6 studies, 181 participants), overall behaviour problems (SMD -0.20, 95% CI -0.56 to 0.17; 6 studies, 209 participants) and cognition (SMD 0.21, 95% CI -0.04 to 0.45; 6 studies, 257 participants). We found moderate-quality evidence that they reduce depressive symptoms (SMD -0.28, 95% CI -0.48 to -0.07; 9 studies, 376 participants), but do not decrease agitation or aggression (SMD -0.08, 95% CI -0.29 to 0.14; 12 studies, 515 participants). The quality of the evidence on anxiety and social behaviour was very low, so effects were very uncertain. The evidence for all long-term outcomes was also of very low quality.

AUTHORS' CONCLUSIONS

Providing people with dementia with at least five sessions of a music-based therapeutic intervention probably reduces depressive symptoms but has little or no effect on agitation or aggression. There may also be little or no effect on emotional well-being or quality of life, overall behavioural problems and cognition. We are uncertain about effects on anxiety or social behaviour, and about any long-term effects. Future studies should employ larger sample sizes, and include all important outcomes, in particular 'positive' outcomes such as emotional well-being and social outcomes. Future studies should also examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

Group engagement in persons with dementia: The concept and its measurement

Although a few papers documented benefits of group therapeutic activities for individuals with dementia, there is a dearth of studies that have investigated the effects of group activities on persons with dementia. This paper introduces a theoretical framework of studying group therapeutic recreational activity, the Comprehensive Process Model of Group Engagement, and an assessment tool, the Group Observational Measurement of Engagement (GOME). We also report the psychometric properties of this assessment. One hundred and four persons with dementia took part in ten different group activities, with each activity conducted twice at random order so that 20 activities were observed for each group of participants. Following each group activity, research and therapeutic recreation staff members used the GOME assessment to independently rate participants on individual-level measures of attendance duration and engagement, and group level measures (e.g., positive and negative interactions among group members). Reliability and validity analyses comparing observer ratings for each group activity on the individual-level measures of attendance and engagement showed good psychometric properties. Different measures collected on a group level differed with respect to their psychometric quality. We present a theoretical framework to understand group engagement and present measures that could be used in future research and practice.

Psychosocial and Environmental Treatment Approaches for Behavioral and Psychological Symptoms in Neurocognitive Disorders: an Update and Future Directions

Nearly all persons with dementia will exhibit behavioral and psychological symptoms (BPSD) at some point during the course of the disease. These symptoms often pose significant challenges for formal and informal caregivers, and their treatment is unclear. Current guidelines recommend implementing nonpharmacological interventions as the first-line approach to managing BPSD. Given the recent proliferation of research evaluating the use of nonpharmacological interventions for BPSD, there is a continuing need to reevaluate and synthesize the findings in this area. The current review examines the evidence for using psychosocial and environmental strategies, focusing on the past 3 years of research efforts and assessing how this research augments what is known from prior reviews. We conclude that the results in the recent literature concerning the efficacy of psychosocial and environmental treatment approaches to behavioral symptoms in dementia continue to be promising, yet results are also mixed. We recommend the consideration of music therapy and tailored activities when utilizing a nonpharmacological approach, as these appear particularly promising throughout the literature. We also find that multisensory stimulation and animal-assisted therapy warrant further evaluation. In contrast, in this and previous reviews, approaches such as bright light therapy and aromatherapy have consistently been shown to be ineffective and, thus, cannot be recommended with confidence based on the evidence. We discuss limitations of current research studies and make recommendations for future research in the area of psychosocial and environmental interventions for BPSD.

Reducing neuropsychiatric symptoms in persons with dementia and associated burden in family caregivers using tailored activities: Design and methods of a randomized clinical trial

Among over 5million people in the USA with dementia, neuropsychiatric symptoms (NPS) are almost universal, occurring across disease etiology and stage. If untreated, NPS can lead to significant morbidity and mortality including increased cost, distress, depression, and faster disease progression, as well as heightened burden on families. With few pharmacological solutions, identifying nonpharmacologic strategies is critical. We describe a randomized clinical trial, the Dementia Behavior Study, to test the efficacy of an activity program to reduce significant existing NPS and associated caregiver burden at 3 and 6months compared to a control group intervention. Occupational therapists deliver 8 in-home sessions over 3months to assess capabilities and interests of persons with dementia, home environments, and caregiver knowledge, and readiness from which activities are developed and families trained in their use. Families learn to modify activities for future declines and use strategies to address care challenges. The comparison group controls for time and attention and involves 8 in-home sessions delivered by health educators who provide dementia education, home safety recommendations, and advanced care planning. We are randomizing 250 racially diverse families (person with dementia and primary caregiver dyads) recruited from community-based social services, conferences and media announcements. The primary outcome is change in agitation/aggression at 3 and 6months. Secondary outcomes assess quality of life of persons with dementia, other behaviors, burden and confidence of caregivers, and cost and cost effectiveness. If benefits are supported, this activity intervention will provide a clinically meaningful approach to prevent, reduce, and manage NPS.