1 / 31

Presented by: Sandy C. Burgener, PhD, GNP – BC, FAAN Associate Professor

Evidence-Based Non-Pharmacological Therapies for Early-Stage Dementia: Implications for Clinical Practice. Presented by: Sandy C. Burgener, PhD, GNP – BC, FAAN Associate Professor University of Illinois College of Nursing Adjunct Associate Professor of Neurology

julie
Download Presentation

Presented by: Sandy C. Burgener, PhD, GNP – BC, FAAN Associate Professor

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Evidence-Based Non-Pharmacological Therapies for Early-Stage Dementia: Implications for Clinical Practice Presented by: Sandy C. Burgener, PhD, GNP – BC, FAAN Associate Professor University of Illinois College of Nursing Adjunct Associate Professor of Neurology Southern Illinois University Center for Alzheimer Disease and Related Disorders Partial funding from: National Alzheimer’s Association, Chicago, Illinois

  2. Support for Non-Pharmacological Therapies for Early-Stage Dementia • Self-identified need of persons with early-stage dementia (Results of AA town hall meetings) • Gap in community-based services: Diagnosis → Adult day care services • Limitations of current drug therapies • Growing body of research supporting positive effects of non-pharmacological therapies

  3. Criteria for Grading the Strength of the Research • A1 = Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action • A2 = Evidence from one or more randomized controlled trials with consistent results • B1 = Evidence from high quality evidence-based practice guidelines • B2 = Evidence from one or more quasi-experimental studies with consistent results • C1 = Evidence from observational studies with consistent results (e.g. correlational, descriptive studies) • C2 = Inconsistent evidence from observational studies or controlled trials • D = Evidence from expert opinion, multiple case reports, or national consensus reports

  4. Theoretical Frameworks Guiding Non-Pharmacological Interventions • Enablement Model • Progressively Lowered Stress Threshold • Need-Driven Dementia-Compromised Behavior Model • Plasticity Theory and the Effects of Enriched Environments on Neuronal Regeneration

  5. Plasticity Theory • Early animal studies suggest brain, after injury, is capable of responding to external stimuli, called ‘enriched environments.’ (EE) (Black, Sirevaag, Greenough, 1987) • EE effects on brain structure: • Increased synapses per neuron. • Increased neuronal density. • New neuronal sprouting: increased numbers of neurons. • Slowing of cell death.

  6. Plasticity Theory (Cont’d) • Behavioral and cognitive effects of EE include: • Increased spatial learning. • Improve overall learning. • Regaining of motor skills. • Inconsistent findings in cell proliferation between groups (EE, exercise only, control) (Briones, et al., 2005)

  7. Enriched Environment Components Based on animal and human (TBI) studies: • Structured exercise (beyond baseline) • Multiple environmental stimuli: • Music • Cognitive tasks • Opportunity to explore environment • Social interactions • Varied, intense stimuli • Novel stimuli

  8. Exercise Interventions: n=11 • 36% = A • 55% = B • 9% = C • Most studies were randomized, controlled trials. • Outcomes include: • Improved cognition. • Improved physical and functional ability. • Less depression. • Fewer behavioral symptoms in exercisers compared to non-exercisers. • Tested exercise forms include: • Home-based aerobic/endurance activities. • Strength training. • Balance and flexibility training. • Tai Chi (2 studies).

  9. Effects of Aerobic Exercise on Brain • Delay or reverse cerebral structural & functional changes* • Delay beta-amyloid accumulation* • Improves memory* • Increases brain-derived neurotrophic factor (BDNF): a neurotrophin associated with learning, cell health *Studies with transgenic mice

  10. Effects of Aerobic Exercise on Brain • Protects against hyperinsulinemia and insulin resistance • Increased dopamine levels in the brain • Increases cerebral vasculature and blood flow

  11. Exercise Studies: Conclusions • Importantly, the exercise type with greatest benefits (animal studies): • Acrobatic exercises • Requires motor learning • Recommended exercise forms: • Aerobic exercises • Exercises that require motor learning, ie, Tai Chi

  12. Cognitive Training & Enhancement Programs: n=41 • 47% = A • 16% = B • 30% = C • 7% = D • Outcomes include: • Improved memory and mental status. • Errorless learning achievement. • Improved executive functioning. • Improved functioning in activities of daily living. • Decreased depression. • Importantly, in longitudinal studies where a control group was used, persons with AD who received a cognitive enhancement intervention maintained higher MMSE scores compared with the control group for up to two years following the intervention.

  13. Effects of Cognitive Training on the Brain • Increased dendritic sprouting • Enhanced CNS plasticity • Improved memory storage and retrieval • Improved executive functioning • Decreased depression • Effects of cognitive training similar to effects of dementia-specific medications on cognitive functioning

  14. Cognitive Training Definitions • Cognitive training: Guided practice on a set of standard tasks designed to reflect particular cognitive functions, such as memory, attention, or problem-solving (executive function). • Cognitive rehabilitation: More individualized approach to helping persons with cognitive impairments with more of an emphasis on improving everyday functioning. Reference: Clare, et al., 2009

  15. Limitations of Cognitive Training Research • Lack of consistency regarding content of intervention • Training effects do not generalize to other functions; positive effects are found only for target cognitive function. • Wide variation in: • Length of intervention • Delivery format (home, group, individual) • Involvement of family caregiver

  16. Early-Stage Support Groups: n=13 • 12% = B • 55% = C • 33% = D • Most include an educational and social support component: 8 to 10 weeks in length • Studies lack a quantitative design and systematic outcome evaluation • Small sample sizes, typically 8 to 20 participants • Age-matched control groups lacking • Participation is ‘terminated’ at the end of the formal sessions, with the exception of the ‘Alzheimer’s Café’ in the Netherlands.

  17. Exemplar Programs: n=14 • 36% = A • 29% = B • 36% = C • Multimodal interventions demonstrate great promise due to power of the intervention and the effects on a variety of outcomes. • Outcomes include: • Improved cognition and physical abilities. • Lower depressive symptoms. • Heightened self-esteem. • Enhanced communication ability. • Despite small sample sizes, technology-based programs offer strong promise for the future as an exemplary method to: • Minimize the need for professional support services. • Be utilized by family caregivers. • Be widely disseminated.

  18. Components of Multi-Modal Interventions Two or more of the following treatments: • Exercise (aerobic, endurance, Taiji, strength training, balance, flexibility training) • Caregiver training in behavior management • Cognitive exercises • Cognitive-behavioral therapies • Reality orientation

  19. Components of Multi-Modal Interventions (Cont’d) • Nutritional intervention (high-protein supplement) • Conversational stimulation • Volunteer service or meaningful community activity • College course • Recreational and social therapies • Family involvement and therapies

  20. Health Promotion Interventions: n=32 • 37% = A • 25% = B • 31% = C • 7% = D • Support for sleep hygiene interventions: • For sleep enhancement in the home-setting, despite limited number of studies • Few definitive dietary recommendations can be made, other than inclusion of naturally occurring antioxidants. Translational research studies need to be conducted.

  21. Health Promotion Interventions (Cont’d) • Falls in persons with early-stage dementia are associated with: • Increased cognitive impairment. • Environmental hazards. • Changes in balance and equilibrium. • Distractions while walking or performing a task. • Few studies have been conducted testing interventions for fall prevention. • College course for health promotion (one study): • Outcomes include: • Lower depression. • Lower anxiety. • Improved self-esteem.

  22. ‘Other’ Interventions • Volunteer Programs: Outcomes include: • Increased language and memory skills • Positive caregiver perceptions of volunteer work for persons with dementia • Writing interventions: Benefits of writing interventions are sparse and descriptive in nature. • Technology-based interventions: • Hampered by the small sample sizes • Limited studies to date • Descriptive in nature, with only one study utilizing a comparison group

  23. Early-Stage Dementia:Non-Pharmacological Treatment Protocol • Multi-modal intervention programs • Physical exercise, preferably aerobic or mindful exercises: • If aerobic exercises cannot be tolerated, then exercises that are less-strenuous yet promote strength, balance, coordination, and require motor learning, such as Tai Chi • Cognitive training programs: Preferably, therapies that use cognitive training and rehabilitation as the focus of the training • Comprehensive college courses and recreational therapies, including such activities as art, writing, social engagement, individualized hobbies • Support group participation (continuous, not time-limited) • Sleep hygiene programs, such as NITE-AD

  24. Early-Stage Dementia:Non-Pharmacological Treatment Protocol • Dietary modifications to include foods that are rich in antioxidants: • Blueberries, spinach, and strawberries • Driving evaluations, at least every 6 months: • Including an on-road test with an experienced driving specialist • Individualized instruction and training in activities to promote independence: • Cell phone usage, computer e-mail programs, etc. • Electronic reminder and monitoring support programs, if not cost prohibitive

  25. Model of Community-Based Non-Pharmacological Treatment Program • Center for Positive Aging: Buettner & Fitzsimmons • Minds in Motion and Lunch & Learn: Burgener • Brookdale-funded programs: Early-Memory Loss Programs

  26. Recruitment and Retention in Early-Stage Programs Brookdale-funded programs recruitment: • Establish positive relationships with collaborative, community agencies: • Adult day care centers • Centers for aging • Geriatric-focused medical practices • Disseminate information in geriatric-focused publications • Positive reputation: Word of mouth

  27. Recruitment and Retention in Early-Stage Programs High retention rates: • Positive outcomes: Experience benefits of program participation • Maintaining appropriate participant level • Collaboration with community groups to transition more impaired participants • Enjoyable, varied activities • Competent, appropriate program leaders

  28. Positive Outcomes of Community-Based Programs • Improved or sustained cognitive functioning compared to controls • Improved (less) depression • Higher QoL scores • Improved self-esteem compared to controls • Improved physical functioning (balance and lower leg strength) • Lower stress • Low attrition rates • Overall improved social functioning

  29. Conclusions • Evidence exists for the effectiveness of a wide variety of non-pharmacological therapies. • Non-pharmacological therapies are rarely recommended following dementia diagnosis. • Availability of non-pharmacological therapies is limited, presenting barriers to participation and possible positive benefits. • Dual therapies may offer significant benefits over medication-therapy alone, but they are not widely tested.

  30. References Bach-y-Rita, P. (2003a). Theoretical basis for brain plasticity after TBI. Brain Injury, 17, 643-651. Bach-y-Rita, P. (2003b). Late postacute neurologic rehabilitation: neuroscience, engineering, and clinical programs. Archives of Physical Medicine and Rehabilitation, 84, 1100-1108. Black, J.E., Sirevaag, A.M., & Greenough, W.T. (1987). Complex experience promotes capillary formation in young rat visual cortex. Neuroscience Letters, 83, 351-355. Boeve, B.F. (2005). Clinical, diagnostic, genetic and management issues in dementia with Lewy bodies. Clinical Science, 109, 343-354. Briones, T.L., Suh, E., Jozsa, L., Rogozinska, M., Woods, J., & Wadowska, M. (2005). Changes in number of synapses and mitochondria in presynaptic terminals in the dentate gyrus following cerebral ischemia and rehabilitation training. Brain Research, 1033, 51-57. Briones, T.L., Suh, E., Hattar, H., & Wadowska, M. (2005). Dentate gyrus neurogenesis after cerebral ischemia and behavioral training. Biological Research in Nursing, 6(3), 167-179. Buettner, L.L. (2006). Peace of mind: a pilot community-based program for older adults with memory loss. American Journal of Recreation Therapy, 13(2), 1-7.

  31. References Buettner, L.L., & Fitzsimmons, S. (2006). Recreation clubs: an outcome-based alternative to daycare for older adults with memory loss. Activities Directors’ Quarterly for Alzheimer’s & Other Dementia Patients, 7(2), 10-20. Burgener, S.C., Yang, Y., Gilbert, R., & Marsh-Yant, S. (2008). The effects of a multi-modal intervention on outcomes of persons with early-stage dementia. American Journal of Alzheimer’s Disease and Other Dementias, 23(4), 382-394. Lazarov, O., Robinson, J., Tang, Y. P., Hairston, I. S., Korade-Mirnics, Z., Lee, V. M., et al. (2005). Environmental enrichment reduces abeta levels and amyloid deposition in transgenic mice. Cell, 120, 701-713. McCurry, S.M., Gibbon, L.E., Logsdon, R.G., Vitiello, M.V., & Teri, L. (2005). Nighttime insomnia treatment and education for Alzheimer’s disease: a randomized, controlled trial. Journal of the American Geriatrics Society, 53(5), 793-802. Mahendra N., & Arkin S. (2003). Effects of four years of exercise, language, and social interventions on Alzheimer’s discourse. Journal of Communication Disorders, 36, 395-422. Siervaag, A.M., Black, J.E., Shafron, D., & Greenough, W.T. (1988). Direct evidence that complex experience increases capillary branching and surface area in visual cortex of young rats. Brain Research, 471, 299-304. Teri, L, & Gallagher-Thompson, D. (1991). Cognitive-behavioral interventions for treatment of depression in Alzheimer’s patients. The Gerontologist, 31, 413-416.

More Related