Maximizing Ability in People with Dementia

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Nonpharmacologic Approaches To Managing
Behavioral 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

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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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Physical Environment
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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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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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Bright Light Therapy
Ancoli-Israel et al. (2003). Am J Geriatr
Psychiatry, 11, 194-203.
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Underlying Mechanisms of Bright Light

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

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Music vs. Conversation
Brotons Koger. (2000). Journal of Music Therapy
XXXVII(3), 183-195.
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Music Therapy Group
Suzuki et al. (2004). Nursing Health Sciences,
6, 11-18.
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Underlying Mechanisms of Music
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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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Underlying Mechanisms of Aromatherapy
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Task Environment
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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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Underlying MechanismsOf Enriched Environment

• Enriched environments training result in
  biochemical changes
• ? cholinergic neural activity
• ? in number of synapses for each neuron

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Cognitive-Motor Intervention
Olazarán et al. (2004). Neurology, 63, 2348-2353.
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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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Person-Centered Shower Towel Bath
Sloane et al. (2004). JAGS, 52, 1795-1804.
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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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Social Environment
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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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Need-Driven Dementia-Compromised Behavior Model
Background factors Neurological factors Cognitive
ability Health status (physical functional
ability) Psychosocial (premorbid personality)
Behavioral symptoms Agitation Passivity
Proximal factors Physiological need
states Psychological need states Physical
environment Social environment
Algase et al. (1996). American Journal of
Alzheimers Disease and Other Dementias, 13(6),
10-19.
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Theory-Based Activities
Kolanowski, Litaker Buettner. (2005). Nursing
Research, 54(4), 219-228.
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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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Exercise Plus Behavior Management
Teri et al. (2003). Journal of the American
Medical Association, 290(15), 2015-2022.
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Meta Analysis of Exercise
Heyn et al. (2004). Arch Phys Med Rehabil 85,
1694-1704.
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Underlying Mechanisms of Exercise
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Home Environmental Intervention
Gitlin et al. (2001). Gerontologist, 41(1), 4-14.
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Snoezelen
Van Weert et al. (2005). JAGS, 53, 24-33.
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Cognition ADL Performance
Appropriate Nonpharmacologic Interventions

Behavioral Symptoms
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