Nonpharmacologic Approaches to Managing Symptoms in Persons with Dementia

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Nonpharmacologic Approaches To Managing
Symptoms In Persons with Dementia
Cornelia Beck, PhD, RN, FAAN Professor Department
of Geriatrics Department of Psychiatry and
Behavioral Sciences Director Memory Research
Center University of Arkansas for Medical Sciences
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Symptom Domains Of Alzheimers Disease

• Activities of Daily Living

Cognition
Behavior
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Key Points

• Non-pharmacologic interventions improve or delay
  decline of cognition, ADLs behavior
• For cognition, effect sizes equal those of
  cholinesterase inhibitors
• For behavior, effect sizes equal those of
  atypical antipsychotics
• Research opportunities abound

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Environment

• Physical manipulation to daily objects,
  structural elements or sensory aspects of
  environment
• Task manipulation to daily routines including
  communication, cueing techniques, ways in which
  persons interact with objects

Gitlin, Liebman Winter. (2003). Alzheimers
Care Quarterly, 4(2), 85-107.
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• Social manipulation to organization, composition
  interactions of social groups
• Combination manipulation to 1 or more of the
  above

Gitlin, Liebman Winter. (2003). Alzheimers
Care Quarterly, 4(2), 85-107.
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Dementia Stage Descriptions
Ashford, Schmitt Kumar. (1998). Advances in the
Diagnosis Treatment of Alzheimers Disease. New
York Springer Publishing Company (111-151).
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Interventions for Cognition

• Physical

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Evening Bright Light Therapy
Graf et al. (2001). Biological Psychiatry, 50,
725-727.
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Rivastigmine vs. Light Therapy
Rivastigmine Trial
Light Therapy Trial
MMSE
Rivastigmine Corey-Bloom et al. (1998).
International Journal of Geriatric
Psychopharmacology, 1, 55-65. Light Therapy Graf
et al. (2001). Biological Psychiatry, 50, 725-727.
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Music vs. Conversation
Brotons Koger. (2000). Journal of Music Therapy
XXXVII(3), 183-195.
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Interventions for Cognition

• Task

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Cognitive Stimulation Therapy
Spector et al. (2003). British Journal of
Psychiatry, 183, 248-254.
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Numbers Needed to Treat Analysis
 

Spector et al. (2003). British Journal of
Psychiatry, 183, 248-254.
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Interventions for Cognition

• Combination

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Music-based Exercise
Van de Winckel et al. (2004). Clinical
Rehabilitation, 18, 253-260.
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Rivastigmine vs. Music-based Exercise
Rivastigmine Trial
Music-based Exercise
MMSE
Rivastigmine Corey-Bloom et al. (1998).
International Journal of Geriatric
Psychopharmacology, 1, 55-65. Music-based
exercise. Van de Winckel et al. (2004). Clinical
Rehabilitation, 18, 253-260.
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Interventions for ADLs

• Physical

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Improved Lighting
Brush, Meehan, Calkins. (2002). Alzheimers
Care Quarterly, 3(4), 330-338.
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Calorie Count
Brush, Meehan, Calkins. (2002). Alzheimers
Care Quarterly, 3(4), 330-338.
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Interventions for ADLs

• Task

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Dressing Independence
Beck et al. (1997). Nursing Research, 46(3),
126-132.
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Purpose of Study

• Examine the difference in dressing assistance
  that subjects received before and after a
  clinical intervention Strategies for Promoting
  Independence in Dressing
• Beck et al. (1997). Nursing Research, 46(3),
  126-132.

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Strategies to Support Functional Performance

• Levels of assistance
• Standard
• Problem oriented

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Level of Assistance Strategies

• No assistance
• Stimulus control
• Verbal prompting
• Gestures, modeling
• Physical prompting/guidance
• Complete assistance

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Standard Strategies

• Communication techniques
• One-step commands
• Choice vs. directive
• Frequent praise
• Caregiver behaviors
• Organized and consistent
• Alert to cues from patient

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Problem-Oriented Strategies

• Redirect to stop perseveration
• Use adaptive equipment
• Modify environment
• Accommodate physical deficits
• Perform tasks that are too difficult

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Mean BDPS Scores by Period
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Mean BDPS Scores

• Baseline 6.17 (se0.17)
• Complete Physical Guidance
• At 6 weeks 4.84 (se0.26)
• Gesturing or modeling
• Post Intervention 4.90 (se0.25)
• Gesturing or modeling
• Follow-up 5.21 (se0.25)
• Occasional physical guidance

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Beck Dressing Performance ScaleMaximum Effect
Score (n90)
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Achievement Of Maximum Effect
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Mean Caregiver Time (in minutes)
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Cognitive Training Programs
Farina et al. (2002). Acta Neurologica
Scandinavica, 105, 365-371.
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Rivastigmine vs. Cognitive Training
Rivastigmine Trial
Cognitive Training Trial
MMSE
Rivastigmine Corey-Bloom et al. (1998).
International Journal of Geriatric
Psychopharmacology, 1, 55-65. Cognitive Training
Farina et al. (2002). Acta Neurologica
Scandinavica, 105, 365-371.
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Nursebot
Pineau et al. (2003). Robotics Autonomous
Systems, 42, 271-281.
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Florence on the Today Show
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Pearl talks with residents at an elder care
facility
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Handwashing
Mihailidis, Barbenel Fernie. (2004).
Neuropsychological Rehabilitation, 14(1-2),
135-171.
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Interventions for ADLs

• Social

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Social Activities Sleep
Richards, Beck, OSullivan Shue. (2004).
Manuscript Submitted.
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Minutes Awake at Night(N50)
p.04
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Interventions for ADLs

• Combination

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Exercise Plus Behavior Management
Teri et al. (2003). Journal of the American
Medical Association, 290(15), 2015-2022.
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Home Environmental Intervention
Gitlin et al. (2001). Gerontologist, 41(1), 4-14.
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Interventions for Behavioral Symptoms

• Physical

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Music Therapy Group
Suzuki et al. (2004). Nursing Health Sciences,
6, 11-18.
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Lemon Balm
Ballard, OBrien, Reichelt Perry (2002). J.
Cin. Psychiatry 63(7), 553-558.
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Differences in Scores on Cohen-Mansfield
Agitation Inventory Subscales
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Interventions for Behavioral Symptoms

• Task

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Person-Centered Shower Towel Bath
Sloane et al. (2004). JAGS, 52, 1795-1804.
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Interventions forBehavioral Symptoms

• Social

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Therapeutic Recreation
Buettner. (2004). University of Arkansas for
Medical Sciences Memory Research Center Lecture
Series 11-09-04.
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Six Categories of Recreation

• Feelings-based (significant calming effect)
• Relaxation-based (significant calming effect)
• Physical-type (significant calming alerting
  effects)
• Cognitive-based (significant calming alerting
  effects)
• Life roles (significant calming slightly less
  significant alerting effect)
• Aroma therapy (no significant effects)

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Cognition ADL Performance
Appropriate Nonpharmacologic Interventions

Behavioral Symptoms
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Research Challenges

• Outcome measures similar to drug trials
• Better understanding of underlying mechanisms
• Genotype effects
• Combination trials
• Computer technology and robotics
• Cost-effectiveness analysis

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Outcome Measures

• Global measures CDR, CIBIC
• Cognitive measures ADAS-Cog, MMSE
• Functional measures
• Quality of life measures
• Behavioral measures NPI
• Caregiver measures

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Underlying Mechanisms

• Bright light
• Effect mediated by hypothalamic suprachiasmatic
  nucleus (SCN)
• Direct and indirect projections of SCN to
  hippocampus are noteworthy

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• Tactile stimulation
• Activates locus coeruleus ? hippocampal
  activity in animal models
• Enriched environments training result in
  biochemical changes
• ? cholinergic neural activity
• ? in number of synapses for each neuron

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Genotype Effects

• Correlation of behavioral symptoms with APOE e4
  alleles found in persons with moderate to severe
  AD, but not in early stage.

Craig, Hart, McCool et.al (2004). J Neurol
Neurosurg Psychiatry, 75, 1327-1330
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APOE-Related Noncognitive Symptoms
Cacabelos et al. (1996). Meth Find Exp Clin
Pharmacol, 18(10), 693-706.
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Combination Trials

• Does an enhanced environment potentiate the
  effect of AChEIs?
• Are the effects of an ADL program improved with
  AChEIs?
• How do caregiver interventions interact with drug
  therapies?

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Incorporation of Computer Technology and Robotics

• Remote presence
• Digital family portrait
• Family intercom
• Gesture pendant and gesture panel
• Assisted cognition systems

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Cost-Effectiveness Analysis

• One in 10 chance that drug will have an effect
  costs 120/month
• Cost-effectiveness remains unclear for AChEIs
• Very few studies on cost of non-pharmacologic
  interventions

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• 67 of dementia-related deaths occur in nursing
  homes.
• 71 of residents with advanced dementia die
  within 6 months of admission, yet only 11 are
  referred to hospice.
• Non-palliative care is quite common in residents
  with dementia including
• 1. tube feeding
• 2. laboratory tests
• 3. restraints
• 4. intravenous therapy

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• End-of-life care for residents with advanced
  dementia involves a number of key issue
• a. Appropriate management o
• symptoms including pain and
  
• behaviors.
• b. Involvement in programs such
  as
• hospice
• c. Decisions about medical
• interventions.
  

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• Aggressive medical treatment for resident with
• advanced dementia
• 1. Is often inappropriate for medical
• reasons
• 2. Has a low rate of success
• 3. Can have negative outcomes that
  hasten
• functional decline and death.

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• Cardiopulmonary resuscitation (CPR) is three
  times less likely to be successful in a person
  with dementia than in one who is cognitively
  intact.
• Those who initially survive are taken to an
  intensive care unit where most die within 24
  hours.

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• Individuals with advanced dementia are more often
  hospitalized than those who are cognitively
  intact or have milder dementia
• Transfer from nursing home to hospital results in
  functional decline that does not improve
  significantly at discharge.
• Patients often develop confusion, anorexia,
  incontinence and falls.
• These symptoms are often managed by aggressive
  medical interventions.

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• The most common cause of hospitalization is
  infection, most often pneumonia, even though
  hospitalization is not necessary for optimal
  treatment.
• Immediate survival and mortality rates are
  similar whether treatment is provided in long
  term care facility or a hospital.
• Long-term outcomes are better in residents
  treated in a nursing home.

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• Intercurrent infections are a common and almost
  inevitable consequence of advanced dementia.
• Antibiotic therapy does not seem to prolong
  survival and is not necessary for symptom
  control.
• When antibiotics are used, they may cause
  significant adverse effects.
• The diagnostic procedures associated with use of
  antibiotics add to the residents confusion and
  discomfort.

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• Tube feeding in residents with advanced dementia
• Does not increase survival.
• Does not prevent aspiration pneumonia,
  malnutrition or pressure ulcers.
• 3) Does not reduce the risk of infections or
  improve functional status of comfort of the
  patient.

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• Quality palliative care is an effective
  alternative to aggressive treatment and is
  closely related to staffing and training in
  nursing homes.

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• Nursing homes are far less likely to hospitalize
  their residents if
• They have dementia special care units.
• They have greater physician-to-patient rations,
  and physician extenders.
• They provide intravenous therapy and provide
  nurse aide training programs.

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• Preventing infection and managing feeding
  problems without resort to tube-feeding can be
  handled by simple strategies such as
• 1. Massage
• 2. Oral Hygiene
• 3. Changes in diet and
• 4. Hand-feeding

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• Guidelines for palliative care in dementia are
  available for clinicians and family members and,
  when applied, have been shown to improve
  end-of-life care.
• Alzheimers Association
• Campaign for Quality Residential Care
• Dementia Care Practice
• Recommendations for Assisted Living Residences
  and Nursing Homes
• Phase 3 End-of-Life Care

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• While there is an expanding body of knowledge
  about the risk and benefits of treatments for
  persons with advanced dementia, there are
  significant barriers to translating that
  knowledge to practice.

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• Physicians overestimate prognosis in persons with
  advanced dementia and have unrealistic
  expectations about the effectiveness of feeding
  tubes.
• A minority discusses end-of-life care with
  families and even fewer provide any advance care
  planning.
• When end-of-life care is discussed, it does not
  often include issues about treatment of infection
  and tube-feeding.

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• Caregivers of person with dementia generally
  select more life-sustaining interventions than
  healthy older adults say they want.
• Family members are not well prepared for their
  role as surrogate decision-makers, have limited
  understanding of dementia progression, and are
  uncomfortable and ambivalent in their role.
• They do not receive sufficient support from
  health care professionals, although this is
  improved if the patient is receiving hospice.

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• Medicaid reimbursement has a direct impact on
  end-of-life care.
• In 26 states, Medicaid pays nursing
  
• homes a higher rate for residents
• who are tube-fed, even though the
  cost
• of care for a resident without a
  feeding
• tube is higher.

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• State Medicaid reimbursement also influences
  hospitalization rates.
• A 10 state study found that an
• increase in the rate of
  reimbursement
• to nursing homes of 10 would
• significantly reduce the risk of
• hospitalization and the odds o
• mortality.

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• Current Medicare guidelines discourage optimal
• end-of-life care for people with advanced
  dementia.
• The guidelines are difficult to apply and have
  been shown to be invalid predictors of survival.

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• Practice Recommendations
• Limits on cardiopulmonary resuscitation
• Increased use of physician extenders in nursing
  homes
• Maintenance of oral health
• Avoidance of antibiotic use
• Increased physician involvement in discussions
  related to end-of-life care, particularly at the
  time of nursing home admission

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• Policy Recommendations
• Elimination of fiscal incentives in Medicaid and
  Medicare for hospitalization and tube-feeding of
  nursing home residents
• Medicare payment for palliative care for
  residents with dementia, and
• National criteria for designation of a surrogate
  decision-maker