Research on psychological interventions in the dementias

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Research on psychological interventions in the
dementias

• Bob Woods
• Bangor University

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Evidence-based practice

• Can psychosocial approaches be subjected to same
  form of evaluation as we require of new drugs?
• They are not so easy to package
• Can rarely be double blind
• A placebo therapy is not always easy
• What works for whom is most important question
• But important to have evidence-base to draw on
• Cochrane reviews important sources of information
• NICE-SCIE Guidelines on management of dementia

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The stages of development of research on a
psychosocial intervention (based on MRC
Framework for evaluation of complex interventions)

• Concept or idea drawn from theory / understanding
  of dementia and/or care-giving
• Intervention development single-case studies,
  pilots, qualitative work
• Outcome measure development
• Rigorous evaluation
• Evaluation of implementation

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Bower, Medical Journal of Australia, 1967
Sensory stimulation

• Sensory deprivation an environment stripped of
  stimulating material, which inevitably surrounds
  such patients either at home or in institutions,
  may well tip the scales and create a state of
  cerebral decompensation, which is attributed to
  the dementing process, but which is, in part at
  least, based on sensory deprivation.

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Bower, Medical Journal of Australia, 1967
Sensory stimulation

• 4.5 hours of structured stimulation per day, 5
  days per week, for 6 months
• Quizzes, music, dance, games, physical exercise,
  jigsaws, industrial assembly work, art, knitting,
  make up etc. etc.
• Patients improved on psychiatric, OT and nursing
  assessments compared with control patients in
  another hospital (N25 in each group)
• Noted that even a weekend rest period led to some
  loss of gains

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Stimulation and activity 2008

• Multi-sensory stimulation (Snoezelen) e.g.
  Baker et al. 1997 reduced behavioural
  disturbance
• Aromatherapy
• Hand massage
• Therapeutic use of music
• Physical exercise
• Creative therapies
• Pet therapy

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One size does not fit all!

• Stimulation and disruptive vocalizations
• Burgio et al (1994) - variety of tactile and
  auditory stimulation - none significant at group
  level
• All associated with improvement for some
  individuals
• Massage aromatherapy
• Brooker et al (1997) 4 single case-studies
• 1 patient improved in hour following treatment 2
  patients worse (?felt constrained)
• Music individual effects?

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Examples of dementia-related psychosocial
research (Bangor University)

• Linda Clare
• Cognitive rehabilitation in dementia (Alzheimers
  Society funded, 2005-2008)
• Awareness in early-stage dementia (ESRC,
  2007-2010)
• Assessing awareness in advanced dementia (MRC
  Trial Platform, 2008-2010)
• Bob Woods
• Meeting needs of people with dementia in care
  homes (Wellcome Trust, 2001-2004)
• Reminiscence therapy (MRC 2004-6 NIHR HTA
  2007-2010 NIHR 2007-2012)
• Cognitive stimulation for people with dementia
  (NIHR 2007-2012)

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Meeting needs of people with dementia in care
homes(Orrell, Challis, Woods, Livingston, Knapp)

• The idea
• People with dementia in care homes have unmet
  needs, systematic approach from liaison service
  required rather than intervention related to
  problems
• The development of the intervention
• individualised interventions, 1 hour per week
  nurse input
• Outcome measure development
• CANE (needs assessment scale identifies met and
  unmet need)
• QoL-AD (13 item self-report measure)
• The rigorous evaluation cluster RCT (Orrell et
  al., 2007)

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Meeting needs of people with dementia in care
homes - 2

• Single-blind, multi-centre cluster RCT, 238
  people with dementia in 24 care homes in 3
  centres (8 homes in North Wales)
• Up to 10 residents with dementia in each home
  assessed with CANE
• 5 month intervention period usual treatment
  v. 1 hour per week nurse visit to pursue action
  plans based on CANE (mainly individual actions)
• Unmet needs reduced in both groups
• Reduction 3.1 intervention / 0.7 control
• No significant difference between groups on CANE
  or QoL-AD
• Importance of systematic assessment - ? Need more
  intensive intervention

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Cognitive rehabilitation for people in early
stages of dementia(Clare, Woods, Linden, Rugg)

• The idea
• Memory rehabilitation effective in other memory
  disorders
• Learning possible in dementia under some
  conditions
• The development of the intervention
• Single-case studies (Clare, 1999 2000 2001)
• Manual 8 individual sessions

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Examples of personal rehabilitation goals (Clare
et al, 2004)

• Using a notebook or diary to keep track of events
• Keeping track of spectacles or keys
• Managing medication
• Making and using a memory book
• Taking up writing again
• Remembering names of partners at bridge club

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Cognitive rehabilitation for people in early
stages of dementia - 2

• Outcome measure development
• fMRI measure of associative learning
• The rigorous evaluation
• 3-arm single-blind RCT for people in early-stage
  Alzheimers (MMSE 18), stable on donepezil
• recruited from Memory Clinics in North Wales
• CR v relaxation v usual treatment
• Target 24 per group gt85 achieved
• Closes September 2008
• Clinical Study Officer support invaluable
• QRD project regular input from carers at
  project meetings

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Awareness in people with early stage
dementia(Clare, Morris, Roth, Markova, Woods)

• The idea
• Awareness of deficits may influence persons
  willingness to participate in / benefit from
  different interventions (Clare et al 2002)
• The development of the intervention
• Will be based on current observational study of
  changes in awareness and its correlates over a 2
  year period (target 100 people with dementia,
  MMSE 18)
• CSO support in recruitment
• Carer and person with dementia on Project
  Advisory Group
• Outcome measure development
• Measures of explicit and implicit awareness being
  developed

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Awareness in people with advanced
dementia(Clare, Woods, Downs, Whittaker)

• The idea
• People with advanced dementia have more awareness
  than is immediately apparent takes careful
  observation and open attitude (Clare et al, 2008)
• Outcome measure development
• Awareness measures used in severe brain injury
  could be adapted for use in this context
• The development of the intervention
• Can staff in care homes use an observational tool
  to improve their awareness of awareness?
• MRC Trial Platform commences in October 2008

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Cognitive stimulation for people with
dementia(Orrell, Woods, Spector)

• The idea
• Small groups based on cognitive activities in a
  social context enhance cognitive function (Holden
  Woods, 1982)
• The development of the intervention
• Based on systematic reviews (Spector et al.,
  2000)
• 14 sessions, twice a week care homes and day
  centres
• Outcome measure development
• QoL-AD means effects beyond cognitive function
  can be evaluated
• The rigorous evaluation (Spector et al., 2003)
• Single-blind RCT 18 care homes, 5 day centres
• 201 participants mean MMSE 14.4 (sd 3.8)
  moderate dementia
• Mean age 85.3
• 167 completed
• Carer member of research team

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Cognitive stimulation for people with dementia -
2

• The evaluation of the implementation
• Manual Making a difference published
• Cognitive stimulation recommended in NICE-SCIE
  Guidelines for people with mild to moderate
  dementia
• Development of Maintenance CST (Orrell et al.,
  2005) weekly sessions
• Maintenance CST and training for staff in CST to
  be evaluated in NIHR Programme SHIELD based at
  UCL

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NICE-SCIE guidance on the management of the
dementias (2006) www.nice.org.uk

• People with mild/moderate dementia of all types
  should be given the opportunity to participate in
  a structured group cognitive stimulation
  programme provided by workers with training and
  supervision irrespective of any anti-dementia
  drug received

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Reminiscence therapy for people with
dementia(Woods, Orrell, Bruce, Keady,
Moniz-Cook, Russell, Edwards)

• The idea
• Joint reminiscence groups for people with
  dementia and carers together are of benefit to
  both (Schweitzer, 1998)
• MRC Trial Platform
• Outcome measure development
• Autobiographical memory
• Quality of relationship
• The development of the intervention
• 12 sessions
• Manual developed (Schweitzer Bruce, 2008)
• Facilitators trained

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Joint Reminiscence Groups

• Originally developed by Age Exchange
  (Reminiscence Theatre charity), led by Pam
  Schweitzer, in context of European project
• Active, large group approach, involving people
  with dementia and carers together
• Volunteers also participate
• Lots of materials, activity, music, dancing,
  laughter refreshments sense of occasion
• Family members encouraged to facilitate not
  dominate

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RYCT Sessions

• Introductions names and places
• Childhood and family life
• School days
• Starting work
• Going out and having fun
• Courting marriage

• Homes, gardens animals
• Food cooking
• The next generation babies children
• Holidays and journeys
• Festivals special days
• Rounding up evaluation

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Reminiscence therapy for people with dementia

• The development of the intervention trial
  platform
• 65 entered trial, 51 completed
• Mean MMSE score 19.3 (sd 5.0)
• Mean age person with dementia 77.4, carer 68.9
• Reminiscence participants show less negative
  change than control participants across most
  measures
• Significant differences on autobiographical
  memory interview and carer depression (GHQ-D),
  favour Reminiscence v. control

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Autobiographical Memory Interview
(Autobiographical incident scale) (Post-treatment
p0.007 follow-up, p0.26)
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Carer depression (GHQ-D)(Post-treatment,
p0.013 Follow-up, p0.024)
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Reminiscence therapy for people with dementia

• The rigorous evaluation HTA trial REMCARE
• 8 centres in Wales England
• Joint reminiscence v usual treatment
• Pragmatic single-blind RCT
• Carer from Trial Platform sits on Trial Steering
  Committee
• 3 groups in each centre, 12 people with dementia
  and carers in each group
• 10 month period includes monthly maintenance
  sessions
• Target recruitment 576
• CSO support vital involved from outset
• First groups start in June

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Thank you!

• b.woods_at_bangor.ac.uk