Non-Pharmacological methods for
management of Dementia
Dr Ravi Soni
Senior Resident First Year
Dept. of Geriatric Mental H...
Discussion over…
• What are BPSD symptoms?
• Prevalence of BPSD symptoms?
• Why there is a need for non pharmacological
me...
Behavioral and Psychological Symptoms of
Dementia (BPSD)
• A heterogeneous range of psychological reactions, psychiatric
s...
Prevalence of BPSD
• 90% of patients affected by dementia will experience
Behavioral and Psychological Symptoms of Dementi...
Impact of BPSD
• 50 – 90% of caregivers considered physical aggression as the
most serious problem they encountered and a ...
Adapted from McShane R. Int
Psychogeriatr 2000;12(suppl 1): 147
BPSD Symptom Clusters
Pacing
Repetitive actions
Dressing/u...
Top Ten Behaviors responsive
(perhaps!) to medication
• Physical aggression
• Verbal aggression
• Anxious, restless
• Sadn...
Top Ten Behaviors not (usually)
responsive to medication
• Hiding/hoarding
• Pushing wheelchair
bound co-patient
• Eating ...
Nature of Behaviors
• Called as Non-Cognitive symptoms
• Now literature prefers the term “Behavioral and
Psychological sym...
Nature of Behaviors
Challenging Behaviors
Behavioral Excess Behavioral Deficits
Behavioral Excess: such as disruptive voca...
Domains of BPSD (Cohen-Mansfield)
• Physically aggressive behaviors
– hitting, kicking, biting
• Physically nonaggressive ...
Nature of Behaviors
• Until recently, main focus of treatment has been excessive behaviors,
because of the disruption they...
Learning/behavioral models
(Cohen-Mansfield)
• Behavior is a learned connection between antecedents,
behavior, reinforceme...
Learning/behavioral models
(Cohen-Mansfield)
1) Identify precisely the problem. The more clearly it is defined,
the easier...
Environmental vulnerability/reduced
stress-threshold model (Cohen-Mansfield)
• The dementia process results in greater vul...
Non Pharmacological Therapies
 Cognitive/Emotion-oriented Interventions:
• Reminiscence Therapy
• Simulated Presence Ther...
Reminiscence Therapy
• Reminiscence therapy involves the discussion of past activities, events and
experiences with anothe...
Evidences….
• O’Donovan (1993), stated that, there is only little indication of cognitive
improvement
• Some evidence sugg...
Validation therapy
• It was suggested by its originator, Naomi Feil, that some of the
features associated with dementia su...
Evidences….
• One systematic review focused on validation therapy for the treatment of
dementia.
• The review included thr...
Simulated presence therapy
(SPT)
• Simulated presence therapy attempts to keep the environment of a patient
with dementia ...
Reality orientation therapy
• most widely used management strategies for dealing
with people with dementia
• It aims to he...
Evidences…..
• Systematic review and meta-analysis of 6 RCTs, with a total of 125
subjects (67 in experimental groups, 58 ...
Behavioral therapies
• Behavioral therapy has been based on principles of conditioning and learning
theory using strategie...
Behavioral therapies
• Token economies (e.g., systems of positive reinforcement for
behaviors),
• Habit training (e.g., re...
Evidences…..
• Three good quality systematic reviews, including a total of 31 studies,
examined the effectiveness of behav...
Sensory Stimulation
Techniques
Light Therapy
Light Therapy
• Rest-activity and sleep-wake cycles are controlled by the endogenous
circadian rhythm generated by the sup...
Evidences….
• Three recent controlled trials have been published with some evidence for
improving restlessness and with pa...
Acupuncture
• Acupuncture is the stimulation of specific acupoints along the skin of the
body involving various methods su...
Aroma Therapy
Aromatherapy
• Aromatherapy is a form of alternative medicine that uses volatile plant
materials, known as essential oils,...
Massage and Touch therapy
Massage and touch therapy
• Massage and touch are among the interventions used in dementia care
• aimed at reducing depres...
Music Therapy
Music Therapy
• People with dementia may retain the ability to sing old songs
• Musical abilities appear to be preserved i...
Evidences…..
• In one study, bathing was accompanied by listening to preferred music (as
compared with no music), resident...
Snoezelen Multisensory Stimulation Therapy
(primarily used for autism and developmental disabilities)
• MSS, otherwise kno...
Snoezelen room
Snoezelen room
Evidences…..
• Systematic reviews identified four additional RCTs and reported mixed
results.
• One study administered MSS...
Transcutaneous Electrical Nerve
Stimulation (TENS)
Transcutaneous Electrical Nerve Stimulation
(TENS)
• TENS is the application of an electrical current through
electrodes a...
Evidences….
• One systematic review of the effectiveness of TENS in the treatment of
dementia has been performed.
• The re...
Art Therapy
• Art therapy has been recommended as a
treatment for people with dementia as
– it has the potential to provid...
Animal-assisted Therapy
 Animal-assisted therapy (AAT):
• Animal-assisted therapy is a goal-directed intervention in
whic...
Animal Assisted Therapy Benefits
• Positive physiological effects (e.g.
decrease heart rate and blood
pressure)
• Mental s...
Examples of AAT Goals
• Physical (e.g. improve fine motor skills,
wheelchair skills, or standing balance)
• Mental Health ...
Types of Animals
• There are many different types of therapy
animals
• Most common are dogs, cats, & horses
Types of Animals Cont.
• Farm animals can be therapeutic as well as smaller or
less common types of animals such as: Rabbi...
Interventions that Assist Goals
• Practice teaching the animal
something new
• engage in play with the animal & other
type...
Evidences…..
• Several small studies suggest that the presence of a dog
reduces aggression and agitation, as well as promo...
Activity therapy
• Activity therapy involves a rather amorphous group of recreations such as
dance, sport and drama.
• It ...
Physical Exercise
 In Early to mild stage of dementia:
• Gardening
• Indoor bowls
• Music and dance
• Seated exercises
– ...
Physical Exercise
Exercise in the later stages of
dementia:
• Physical activity can also be beneficial in the later
stage...
Physical Exercise
 Suggested exercises in the later stages of dementia
• When getting up or going to bed, move along the ...
Time Duration for Exercise in late Stages
• People in the later stages of dementia should
be encouraged to move about regu...
Benefits…
• improving physical function - maintaining muscle strength and
joint flexibility can be a way of helping people...
Evidences….
• Eggermont et al.’s (2006) review includes a wider range of trials which
shows that, though a number of studi...
Wandering-Definition
• “A tendency to move about either in
a seemingly aimless or disoriented
fashion, or in pursuit of an...
Situations leading to wandering
• The person walks about their environment and
cannot find his/her way back.
• The caregiv...
How to deal with wandering??
 Structured day:
– Structuring the activities of the day keeps the patient busy and is helpf...
How to deal with wandering?
• Distraction: the aim is to the dementing patient to forget his/her
intention to wander and d...
How to deal with wandering?
• Visual Barriers (Namazi et al, 1989): visual
barriers to hide exit also reduce the
wandering...
Evidences….
• Traditional measures to reduce wandering include drugs, restraints,
locked doors, and other barriers; but su...
Evidences….
• Another Cochrane review sought to examine interventions for wandering
of people with dementia in the domesti...
Evidences….
• A descriptive review of information and communication technology (ICT)
devices identified 13 interventions t...
Agitation in Dementia
• Is a Behavioural symptom
– Defined as : “Inappropriate
verbal, vocal or motor activity
that is not...
Managing Agitation in Dementia
• General Management principles :
– Prevention is more rewarding than
treatment
– Non –phar...
General Approach to New/Upsetting Behaviors
• Check for underlying causes:
– Unmet needs (toileting, hunger, thirst etc)
–...
• Be aware of the persons functional abilities.
• Check your communication style:
– Speak slowly, clearly, respectfully.
–...
ABC’s of General Behavioral Interventions
• A-Antecedent:
– what was happening before the incident or behavior occurred?
W...
Evidences….
• The review identified 14 randomized trials (combined number of
subjects=586) that included six types of inte...
Evidences…..
• One study documented a randomized, placebo-controlled trial of a
systematic individualized intervention des...
Inappropriate sexual behaviour
• Inappropriate sexual behaviours:
– Sexual behaviours that are inappropriate in a given
en...
Nonpharmacological treatment of ISB
• Always involve the caregivers and families in the
treatment plan.
• If the behaviour...
Nonpharmacological treatment of isb
Behavioural modifications
For public behaviours:
• Sensitive explanation of inappropri...
Evidences…..
• There were no systematic reviews that examined the
topic of inappropriate sexual behavior among
individuals...
Urinary Incontinence
• Definition: Urinary incontinence (UI) is any
involuntary leakage of urine.
• It is a common and dis...
Classification of urinary incontinence
• Transient incontinence:
– It is a reversible kind of incontinence. The treatment ...
Behavioral
Interventions
• First line therapy
• Simple measures
• reduce amount and timing of fluid intake
• avoid bladder...
Behavioral Interventions
 Patient Dependent Behavioral Interventions
• Targeted towards mobile, motivated seniors.
• Seni...
Behavioral Interventions Caregiver Dependent Behavioral Interventions
• (also known as toileting assistance) are targeted...
Evidences…..
• There is no evidence of effectiveness for habit retraining (n=1 study) and
timed voiding (n=1 study).
• Pro...
Environmental Modifications
Getting in and out of the home due to
forgetfulness, changes in visual perception (i.e.,
depth...
Increase lighting & visual contrast to ensure safety (in
ambulation) and maintain independence
Increase lighting & visual ...
Add assistive features or eliminate level changes to
ensure safety and maintain independence
Add assistive features or eli...
Add assistive features or remove obstacles at doors
to ensure safety and maintain independence
Add assistive features or r...
Use prompts/reminders at doors
to maximize orientation and maintain independence
Use prompts/reminders at doors
to maximiz...
Therapeutic garden
• SENSORY GARDEN (fines
herbes, flowers, etc.)
• Appréciation of nature and
outdoors
• Inviting space (...
Walking path
• E-B Principles –Walking Path
• Straight connection between
common space
• Day light at the end of the
corri...
93
E-B Principles Environment as a Behavior
Regulator
Each common space is clear in its meaning,
dining area, living area,...
94
Camouflage alarm
95
Garden access and security
- Garden adjacent
- Lock on ramp entrance
- Lock on gate
- Garden can be surveyed
- Planters...
96
Therapeutic garden
THE END
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Non-pharmacological management of dementia

  1. 1. Non-Pharmacological methods for management of Dementia Dr Ravi Soni Senior Resident First Year Dept. of Geriatric Mental Health KGMU, LUCKNOW
  2. 2. Discussion over… • What are BPSD symptoms? • Prevalence of BPSD symptoms? • Why there is a need for non pharmacological methods for management of dementia? • Behaviors, which are not responsive to medications require non pharmacological management. • Non pharmacological methods • Discussion of each Method • Evidences of effectiveness
  3. 3. Behavioral and Psychological Symptoms of Dementia (BPSD) • A heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology. • Any verbal, vocal, or motor activities not judged to be clearly related to the needs of the individual or the requirements of the situation. • An observable phenomena (not just internal)
  4. 4. Prevalence of BPSD • 90% of patients affected by dementia will experience Behavioral and Psychological Symptoms of Dementia (BPSD) that are severe enough to be labeled as a problem during the course of their illness.  Most common: • Agitation (75%) • Wandering (60%) • Depression (50%) • Psychosis (30%) • Screaming and violence (20%)
  5. 5. Impact of BPSD • 50 – 90% of caregivers considered physical aggression as the most serious problem they encountered and a factor leading to institutionalization. (Rabins et al. 1982) • Front-line staff working in LTC (long term care) report that physical assault contributes to significant work related stress (Wimo et al. 1997) • Agitation, depression, anxiety, paranoid ideation cause significant suffering.
  6. 6. Adapted from McShane R. Int Psychogeriatr 2000;12(suppl 1): 147 BPSD Symptom Clusters Pacing Repetitive actions Dressing/undressing Restless/anxious Hallucinations Delusions Misidentification Suspicious Agitation Physical aggression Verbal Aggression Aggressive resistance to care Sad Tearful Hopeless Guilty Anxious Irritable/screaming Suicidal Withdrawn Lacks interest Amotivation Psychosis Depression Apathy Aggression Euphoria Pressured speech Irritable Mania
  7. 7. Top Ten Behaviors responsive (perhaps!) to medication • Physical aggression • Verbal aggression • Anxious, restless • Sadness, crying, anorexia • Withdrawn, apathetic • Sleep disturbance • Wandering with agitation/aggression • Vocally repetitious behavior • Delusions and hallucinations • Sexually inappropriate behavior with agitation
  8. 8. Top Ten Behaviors not (usually) responsive to medication • Hiding/hoarding • Pushing wheelchair bound co-patient • Eating in-edibles • Inappropriate isolation • Tugging at/ removal of restraints • Aimless wandering • Inappropriate urination /defecation • Inappropriate dressing /undressing • Annoying perseverative activities • Vocally repetitious behavior
  9. 9. Nature of Behaviors • Called as Non-Cognitive symptoms • Now literature prefers the term “Behavioral and Psychological symptoms of Dementia” (BPSD) • In Psychology Community term favored is “Challenging Behaviors”
  10. 10. Nature of Behaviors Challenging Behaviors Behavioral Excess Behavioral Deficits Behavioral Excess: such as disruptive vocalization or aggression Behavioral Deficits: such as lack of social interaction or lack of self-care
  11. 11. Domains of BPSD (Cohen-Mansfield) • Physically aggressive behaviors – hitting, kicking, biting • Physically nonaggressive behavior – pacing, inappropriate touching • Verbally nonaggressive agitation – repetitive phrases or requests, calling out • Verbally aggressive behaviors – cursing, screaming
  12. 12. Nature of Behaviors • Until recently, main focus of treatment has been excessive behaviors, because of the disruption they cause both for the person with dementia and the carers. • Disruptive behaviors are taken as an indication of underlying distress or unmet need. • For example: UNMET NEED MODEL for AGITATION by Cohen-Mansfield (2000). • It distinguishes three main functions of behaviors in relation to needs: 1. Behaviors to obtain or meet a need (e.g. pacing to provide stimulation); 2. Behaviors to communicate a need (e.g. repetitive questioning); 3. Behaviors that result from an unmet need (e.g. aggression triggered by pain or discomfort).
  13. 13. Learning/behavioral models (Cohen-Mansfield) • Behavior is a learned connection between antecedents, behavior, reinforcement • Many problem behaviors are learned through reinforcement by staff members, who provide attention when problem behavior is displayed. • ABC approach – A = antecedent or triggering event that precedes the problem behavior – B= the behavior of concern – C= the consequence of that behavior • Changing either the antecedent or the consequence may change the behavior
  14. 14. Learning/behavioral models (Cohen-Mansfield) 1) Identify precisely the problem. The more clearly it is defined, the easier it is to implement an effective response 2) Gather information about the circumstances surrounding the problem immediately before and after. There may be several triggers 3) Set realistic goals, and make plans to achieve them. Seek to be creative, realistic and tailored to the individual and caregivers. "Increasing pleasant activity" is more realistic than "be happy all the time.“ 4) Encourage rewards (to all) for small successes. Changing behavior is hard work for everyone. 5) Continually evaluate and modify plans. Consistency but flexibility. Strategies may need to change.
  15. 15. Environmental vulnerability/reduced stress-threshold model (Cohen-Mansfield) • The dementia process results in greater vulnerability to surroundings and a greater chance that an event will affect behavior. • Persons with dementia progressively lose their coping abilities and therefore perceive their environment as more and more stressful. • Concurrently, their likelihood of being bothered by the environment increases, resulting in anxiety and inappropriate behavior when the environmental stimuli exceed the threshold for tolerating the stress • An environment of reduced stimulation is supposed to limit the stress experienced and thereby reduce the level of inappropriate behavior • Relaxation will reduce the stress and thereby decrease the undesirable behavior.
  16. 16. Non Pharmacological Therapies  Cognitive/Emotion-oriented Interventions: • Reminiscence Therapy • Simulated Presence Therapy (SPT) • Validation Therapy • Reality Orientation Therapy  Sensory Stimulation Interventions: • Acupuncture • Aromatherapy • Light Therapy • Massage and Touch Therapy • Music Therapy • Snoezelen Multisensory Stimulation Therapy • Transcutaneous Electrical Nerve Stimulation (TENS)  Behavior Management Techniques:  Other Psychosocial Interventions: • Animal-assisted Therapy (AAT) • Exercise  Various Interventions Targeting a Specific Behavioral Symptom • Wandering • Agitation • Inappropriate Sexual Behavior
  17. 17. Reminiscence Therapy • Reminiscence therapy involves the discussion of past activities, events and experiences with another person or group of people. • Uses materials such as old newspapers, photographs, household and other familiar items from the past to stimulate memories and enable people to share and value their experiences. 1. Group sessions: to improve interaction 2. Individual sessions: life review sessions, in which the person is guided chronologically through life experiences and encouraged to evaluate them • It is seen as a way of increasing levels of well-being and providing pleasure and cognitive stimulation. • Studies have suggested that reminiscence work assists in reducing depression in older people
  18. 18. Evidences…. • O’Donovan (1993), stated that, there is only little indication of cognitive improvement • Some evidence suggesting improvements in behavior, well-being, social interaction, self-care and motivation (Gibson, 1994) • It is also claimed that premorbid aspects of the person’s personality may re-emerge during reminiscence work (Woods, 1999). • One systematic review has been found for Reminiscence Therapy as a treatment of Dementia • Four RCTs that included a combined total of 144 subjects were included in the findings of this review. • Three of the RCTs assessed behavioral symptoms and found no effect of reminiscence therapy on these symptoms. • One RCT (N=17) compared the effects of 12 individual weekly sessions of reminiscence therapy with no treatment, and found statistically significant improvements in depression at six weeks in the treatment group, but found no differences in other behavioral symptoms between groups.
  19. 19. Validation therapy • It was suggested by its originator, Naomi Feil, that some of the features associated with dementia such as repetition and retreating into the past were in fact active strategies on the part of the affected individual to avoid stress, boredom and loneliness. • The idea behind validation therapy is to “validate” or accept the values, beliefs and “reality” of the person suffering from dementia. • The key is to “agree” with them, but to also use conversation to get them to do something else without them realizing they are actually being redirected. • Therapists therefore attempt to communicate with individuals with dementia by empathizing with the feelings and meanings hidden behind their confused speech and behavior. • It is the emotional content of what is being said that is more important than the person’s orientation to the present.
  20. 20. Evidences…. • One systematic review focused on validation therapy for the treatment of dementia. • The review included three RCTs with a combined total of 146 subjects. • Comparison groups: usual care, reality orientation therapy, validation therapy, social contact • study found a significant difference in Behavior Assessment Tool (BAT) scores in favor of validation therapy compared to usual care, but there were no significant differences between validation therapy and reality orientation therapy. • In a study of 88 patients from four nursing homes, a beneficial effect on depression was observed at 12 months in favor of validation therapy compared with social contact, but there was no difference compared to usual care. • Three additional systematic reviews found no additional benefit of validation therapy over other forms of therapy.
  21. 21. Simulated presence therapy (SPT) • Simulated presence therapy attempts to keep the environment of a patient with dementia as familiar as possible to reduce anxiety and distress. • It involves making a recording of a familiar person and playing it to the patient. • The recorded voice is usually reassuring but the content can be varied depending upon the interests of the individual patient concerned.  Evidences…. • One systematic review that focused on SPT for the treatment of behavioral symptoms of dementia. • A meta-analysis found a statistically significant effect of SPT on disruptive, agitated, or depressed behaviors from pre- to post-intervention, but this analysis was based on three small experimental studies (ranging from six to nine subjects in each) and one small RCT (N=30). • Some studies identified which shows increased agitation and challenging behaviors
  22. 22. Reality orientation therapy • most widely used management strategies for dealing with people with dementia • It aims to help people with memory loss and disorientation by reminding them of facts about themselves and their environment. • can be used both with individuals and with groups. • In either case, can be oriented to their environment using a range of materials and activities. • This involves consistent use of orientation devices such as signposts, notices and other memory aids.
  23. 23. Evidences….. • Systematic review and meta-analysis of 6 RCTs, with a total of 125 subjects (67 in experimental groups, 58 in control groups). • Results were divided into 2 subsections: cognition and behavior. • Change in cognitive and behavioral outcomes showed a significant effect in favor of Reality Orientation. • Reality orientation sessions could increase people’s verbal orientation in comparison with untreated control groups. (Bleathman & Morton, 1988) • has also been claimed that reality orientation can remind the participants of their deterioration (Goudie & Stokes, 1989).
  24. 24. Behavioral therapies • Behavioral therapy has been based on principles of conditioning and learning theory using strategies aimed at suppressing or eliminating challenging behaviors.  Behavioral analysis is the starting point • requires a period of detailed assessment in which the triggers, behaviors and reinforcers (also known as the ABC: antecedents, behaviors and consequences) are identified and their relationship made clear to the patient. • The therapist will often use chart or diary to gather information about the manifestations of a behavior and the sequence of actions leading up to it.  Emerson (1998) suggests focusing on three key features when designing an intervention: 1. Taking account of the individual’s preferences; 2. Changing the context in which the behavior takes place; and 3. Using reinforcement strategies and schedules that reduce the behavior.
  25. 25. Behavioral therapies • Token economies (e.g., systems of positive reinforcement for behaviors), • Habit training (e.g., reinforced learning of habits related to activities of daily living), • Progressive muscle relaxation, • Communication training, • Behavioral or cognitive-behavioral therapy, and • Various types of individualized behavioral reinforcement strategies • These interventions can be implemented directly with the patient or taught to caregivers to implement with the patient.
  26. 26. Evidences….. • Three good quality systematic reviews, including a total of 31 studies, examined the effectiveness of behavior management techniques for the treatment of behavioral symptoms of dementia. • An additional 11 articles focused on teaching caregivers to implement behavior management techniques with individuals with dementia • documented some decreases in behavioral symptoms of dementia; • Seven RCTs from the systematic reviews provided mixed evidence for the effectiveness of behavior management techniques. • Ayalon et al. (2006) described the interventions as possibly efficacious, and noted the need for replication and further research. • Logsdon et al. (2007) described two effective behavior management techniques, structured behavioral interventions and individualized interventions designed to target behavioral symptoms, as being effective in the treatment of dementia-related behavior symptoms;
  27. 27. Sensory Stimulation Techniques
  28. 28. Light Therapy
  29. 29. Light Therapy • Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. • Degenerative changes in the SCN appear to be a biological basis of circadian disturbances in people with dementia. • In addition to the internal regulatory loss, elderly people (especially those with dementia) experience a reduction in sensory input because – they are visually less sensitive to light and – have less exposure to bright environmental light • Evidence suggests that circadian disturbances may be reversed by stimulation of the SCN by light. • bright-light therapy has been increasingly used in an attempt to improve fluctuations in diurnal rhythms that may account for night-time disturbances and ‘sundown syndrome’
  30. 30. Evidences…. • Three recent controlled trials have been published with some evidence for improving restlessness and with particular benefit for sleep disturbances (e.g. see Haffmanns et al, 2001). • One Cochrane review examined RCTs of the effects of light therapy on sleep, behavior, and mood disturbances among patients with dementia in long-term care facilities. – No positive outcome • Another RCT randomly assigned 92 nursing home residents with severe Alzheimer’s disease to receive morning bright light, evening bright light, or morning dim red light for 10 days. – The study found no differences between groups in sleep duration or agitation at the end of therapy and at five days post-treatment. • An older systematic review included four studies of bright light therapy, three of which reported beneficial effects on agitation and nocturnal restlessness during bright light treatment (1500 – 2500 lux). – The studies were limited by small sample size (N < 24), and three of the studies had samples of 10 subjects or fewer.
  31. 31. Acupuncture • Acupuncture is the stimulation of specific acupoints along the skin of the body involving various methods such as the application of heat, pressure, or laser or penetration of thin needles. • It is a key component of traditional Chinese medicine (TCM), which aims to treat a range of conditions and has been used for both the prevention and treatment of diseases for over 3,000 years. • It is a form of complementary and alternative medicine. • Evidences…. – One systematic review evaluated acupuncture in patients with vascular dementia – 17 RCTs were included but none of it qualified for the review – the effectiveness and safety of acupuncture could not be analyzed.
  32. 32. Aroma Therapy
  33. 33. Aromatherapy • Aromatherapy is a form of alternative medicine that uses volatile plant materials, known as essential oils, and other aromatic compounds for the purpose of altering a person's mind, mood, cognitive function or health. • It has been used in attempts to reduce behavioral symptoms, to promote sleep, and to stimulate motivational behavior in people with dementia.  Evidences….. • Systematic review found that aromatherapy was associated with decreased agitation among dementia patients. • One systematic review focused solely on aromatherapy, but only one RCT met its inclusion criteria. • This clustered RCT included 72 participants with severe dementia in eight nursing homes. • The four-week study examined the effects of topical Melissa oil, and sunflower oil was used at control nursing homes. – study found a significant decrease in measures of agitation and neuropsychiatric symptoms, – there was no significant decrease in aggression, and important differences among participants such as medication use were not accounted for.
  34. 34. Massage and Touch therapy
  35. 35. Massage and touch therapy • Massage and touch are among the interventions used in dementia care • aimed at reducing depression, anxiety, aggression and other related psychological and behavioral manifestations. • Expressive touch such as patting or holding a client’s hand involves emotional intent – for example, to calm a patient or to show concern  Evidences…. – One RCT of 42 institutionalized patients with organic brain syndrome compared verbal encouragement with touch to verbal encouragement alone during meals, and found that touch therapy was associated with a significant increase in mean calorie and protein intake. • The second RCT assessed the effect of hand massage vs. calming music, and simultaneous hand massage and calming music vs. no intervention. – Sixty-eight participants were randomly assigned to one of four groups. – Interventions consisted of a single 10-minute treatment. – They found a greater decrease in agitated behavior (CMAI score) compared with baseline during treatment, immediately after treatment, and one hour after treatment among the groups receiving hand massage compared to the group receiving no treatment.
  36. 36. Music Therapy
  37. 37. Music Therapy • People with dementia may retain the ability to sing old songs • Musical abilities appear to be preserved in individuals with dementia who were musicians despite aphasia and memory loss. • Information presented in a song context appears to enhance retention and recall of information, and structured music activities can promote interaction and communication. • Music therapy can, therefore, potentially enhance cognitive skills as well as social/emotional skills, and may also serve as an alternative to medication for managing behavioral symptoms of AD. • There is a wide range of music interventions for older people with dementia, – listening to different types of music, – instrument playing, or – group exercise while listening to music. • The range of music interventions includes – activities administered by a professional music therapist, – presentation of recorded music by a variety of caregivers, to patients privately or in a group setting.
  38. 38. Evidences….. • In one study, bathing was accompanied by listening to preferred music (as compared with no music), residents demonstrated significantly less aggressive behaviors. • Gerdner (2000) reports that agitation was significantly less frequent during and after music therapy when each patient listened to his or her preferred music compared with standard classical music. • Groene (1993) reported that the amount of time a wandering subject remained seated or in close proximity to the session area was longer for music sessions than for reading sessions. • Systematic reviews that included a wider range of study designs consistently concluded that music therapy decreases agitation in the short-term, although there was no evidence of long-term effects. • A systematic review of eight studies that specifically examined the use of preferred or individualized music found reductions in agitated behaviors that were statistically significant in all but one study.
  39. 39. Snoezelen Multisensory Stimulation Therapy (primarily used for autism and developmental disabilities) • MSS, otherwise known as Snoezelen therapy, is based on the premise that neuropsychiatric symptoms may result from periods of sensory deprivation. • It uses multiple stimuli during a treatment session aimed at stimulating the primary senses of sight, hearing, touch, taste and smell. • It combines the use of such treatments as lights, tactile surfaces, music, and aroma. • Interventions generally occur in specially designed rooms with a variety of sensory based materials. – A typical MSS room provides taped music, aroma, bubble tubes, fiber optic sprays and moving shapes projected across walls. – The combination of different materials on a wall may be explored using tactile senses, and the floor may be adjusted to stimulate the sense of balance. • MSS has become a popular intervention for behavioral symptoms in persons with dementia, but the application of MSS varies in form, procedures, and in frequency of treatment.
  40. 40. Snoezelen room
  41. 41. Snoezelen room
  42. 42. Evidences….. • Systematic reviews identified four additional RCTs and reported mixed results. • One study administered MSS in specially designed rooms in 30- to 60- minute sessions and found that during the four-week treatment period, – disruptive behavior outside the treatment setting briefly improved but did not last once the treatment had stopped. • Two studies conducted MSS sessions for 30 to 60 minutes for three consecutive days and found – subjects were less apathetic when remaining in a multisensory stimulation room compared with remaining in the living room or receiving activity therapy. • One small (N=20) repeated-measures study set in a day-care center and mental health nursing home exposed patients to three 40-minute sessions of either MSS or reminiscence therapy and found – no significant differences in behavior symptoms during or after treatment.
  43. 43. Transcutaneous Electrical Nerve Stimulation (TENS)
  44. 44. Transcutaneous Electrical Nerve Stimulation (TENS) • TENS is the application of an electrical current through electrodes attached to the skin. – Short, pulsed electrical currents are generated by a portable pulse generator and delivered across the intact surface of the skin through conditioning pads called electrodes. – By carefully adjusting the intensity and duration of the pulses, a mild tingling sensation without pain or muscle contraction, or – a stronger sensation involving muscle contraction, can be produced. Few known side effects exist and there are no known drug interactions. • Although TENS is not routinely used for treatment of dementia, several studies in the Netherlands and one study in Japan suggest that – TENS applied to the back or head may improve cognition, behavior, and sleep disorders in patients with Alzheimer’s disease or multi-infarct dementia.
  45. 45. Evidences…. • One systematic review of the effectiveness of TENS in the treatment of dementia has been performed. • The review reported that TENS produced a statistically significant improvement directly after treatment in delayed recall of eight words in one trial, face recognition in two trials and motivation in one trial, but • There were no significant effects of TENS treatment on sleep disorders or behavior disorders evaluated immediately after treatment or at six-week post-treatment. • “Although a number of studies suggest that TENS may produce short lived improvements in some neuropsychological or behavioral aspects of dementia, the limited presentation and availability of data from these studies does not allow definite conclusions on the possible benefits of this intervention”
  46. 46. Art Therapy • Art therapy has been recommended as a treatment for people with dementia as – it has the potential to provide meaningful stimulation, – improve social interaction and – improve levels of self-esteem (Killick & Allan 1999) • Activities such as drawing and painting are thought to provide individuals with the opportunity for self-expression and the chance to exercise some choice in terms of the colors and themes of their creations. • Therapy is lacking supportive evidence from research….
  47. 47. Animal-assisted Therapy  Animal-assisted therapy (AAT): • Animal-assisted therapy is a goal-directed intervention in which an animal is an integral part of the treatment process. AAT is directed and/or delivered and documented by a health/human service professional with a specific clinical goal in mind.  Animal-assisted therapy (AAT): • Animal-assisted therapy is a goal-directed intervention in which an animal is an integral part of the treatment process. AAT is directed and/or delivered and documented by a health/human service professional with a specific clinical goal in mind.
  48. 48. Animal Assisted Therapy Benefits • Positive physiological effects (e.g. decrease heart rate and blood pressure) • Mental stimulation (e.g. recall memories) • Feelings of acceptance and good rapport • Outward focus • Opportunities for empathy and nurturing • Increased motivation • Entertainment and socialization • Positive physiological effects (e.g. decrease heart rate and blood pressure) • Mental stimulation (e.g. recall memories) • Feelings of acceptance and good rapport • Outward focus • Opportunities for empathy and nurturing • Increased motivation • Entertainment and socialization
  49. 49. Examples of AAT Goals • Physical (e.g. improve fine motor skills, wheelchair skills, or standing balance) • Mental Health (e.g. increase attention skills, reduce anxiety, reduce loneliness) • Educational (e.g. improve knowledge of concepts such as size, color, etc.) • Motivational (e.g. improve willingness to be involved in activities and to interact with others) • Physical (e.g. improve fine motor skills, wheelchair skills, or standing balance) • Mental Health (e.g. increase attention skills, reduce anxiety, reduce loneliness) • Educational (e.g. improve knowledge of concepts such as size, color, etc.) • Motivational (e.g. improve willingness to be involved in activities and to interact with others)
  50. 50. Types of Animals • There are many different types of therapy animals • Most common are dogs, cats, & horses
  51. 51. Types of Animals Cont. • Farm animals can be therapeutic as well as smaller or less common types of animals such as: Rabbits, Birds, Fish, Hamsters • Each animal has specific skills & abilities to contribute to the therapeutic process. • Farm animals can be therapeutic as well as smaller or less common types of animals such as: Rabbits, Birds, Fish, Hamsters • Each animal has specific skills & abilities to contribute to the therapeutic process.
  52. 52. Interventions that Assist Goals • Practice teaching the animal something new • engage in play with the animal & other types of appropriate interactions • learn about & practice care, grooming, & feeding of the animal • learn other information about the animal • reminisce about the animal or past animals • remember & repeat information about the animal to others • Practice teaching the animal something new • engage in play with the animal & other types of appropriate interactions • learn about & practice care, grooming, & feeding of the animal • learn other information about the animal • reminisce about the animal or past animals • remember & repeat information about the animal to others
  53. 53. Evidences….. • Several small studies suggest that the presence of a dog reduces aggression and agitation, as well as promoting social behavior in people with dementia. • One study has shown that aquaria in dining rooms of dementia care units stimulate residents to eat more of their meals and to gain weight but is limited by the small number of facilities studied. • There is preliminary evidence that robotic pets may provide pleasure and interest to people with dementia. • Several small studies suggest that the presence of a dog reduces aggression and agitation, as well as promoting social behavior in people with dementia. • One study has shown that aquaria in dining rooms of dementia care units stimulate residents to eat more of their meals and to gain weight but is limited by the small number of facilities studied. • There is preliminary evidence that robotic pets may provide pleasure and interest to people with dementia. Susan L. Filan and Robert H. Llewellyn-Jones : Animal-assisted therapy for dementia: a review of the literature,. International Psychogeriatrics(2006), 18:4, 597–611C 2006 International Psychogeriatric Association, doi:10.1017/S1041610206003322
  54. 54. Activity therapy • Activity therapy involves a rather amorphous group of recreations such as dance, sport and drama. • It has been shown that these activities can have a number of health benefits for people with dementia, for example • reducing the number of falls and • improving mental health and sleep (King et al, 1997) • improving their mood and confidence (Young & Dinan, 1994). • in a small-scale controlled study that daytime exercise helped to reduce daytime agitation and night-time restlessness. Alessi et al (1999) • An interesting approach to dance therapy is described by Perrin (1998), who employed a form of dance known as ‘jabadeo’, – which involves no prescriptive steps or motions – allows the participants to engage with each other in interactive movements – This may also fulfill a need for non-sexual physical contact which many people with dementia find soothing
  55. 55. Physical Exercise  In Early to mild stage of dementia: • Gardening • Indoor bowls • Music and dance • Seated exercises – marching – turning the body from side to side – raising the heels and toes – bending the arms – bending the legs – clapping under the legs – bicycling the legs – making circles with the arms – raising the opposite arm and leg – Practising moving from sitting to standing. • Swimming • Tai chi/qigong: Tai chi and qigong are gentle forms of Chinese martial arts that combine simple physical movements and meditation with the aim of improving balance and health • Walking People who are not currently active should be doing about 30 minutes of activity at least five days a week Factsheet: Exercise and physical activity for people with dementia, Alzheimer’s Society
  56. 56. Physical Exercise Exercise in the later stages of dementia: • Physical activity can also be beneficial in the later stages of dementia. • It may help to reduce the need for more supported care and minimize the adaptations needed to the home or surroundings. • Exercises can range from changing position from sitting to standing, walking a short distance into another room or moving to sit in a different chair at each mealtime throughout the day. Exercise in the later stages of dementia: • Physical activity can also be beneficial in the later stages of dementia. • It may help to reduce the need for more supported care and minimize the adaptations needed to the home or surroundings. • Exercises can range from changing position from sitting to standing, walking a short distance into another room or moving to sit in a different chair at each mealtime throughout the day. Factsheet: Exercise and physical activity for people with dementia , Alzheimer’s
  57. 57. Physical Exercise  Suggested exercises in the later stages of dementia • When getting up or going to bed, move along the edge of the bed, in the sitting position, until the end is reached. This helps exercise the muscles needed for standing up from a chair. • Balance in a standing position. This can be done holding onto a support if necessary. This exercise helps with balance and posture and can form part of everyday activities such as when showering or doing the washing up. • Sit unsupported for a few minutes each day. This exercise helps to strengthen the stomach and back muscles used to support posture. This activity should always be carried out with someone else present as there is a risk of falling. • Lie as flat as possible on the bed for 20-30 minutes each day. This exercise allows for a good stretch and gives the neck muscles a chance to relax. • Stand up and move regularly. Moving regularly helps to keep leg muscles strong and maintain good balance.  Suggested exercises in the later stages of dementia • When getting up or going to bed, move along the edge of the bed, in the sitting position, until the end is reached. This helps exercise the muscles needed for standing up from a chair. • Balance in a standing position. This can be done holding onto a support if necessary. This exercise helps with balance and posture and can form part of everyday activities such as when showering or doing the washing up. • Sit unsupported for a few minutes each day. This exercise helps to strengthen the stomach and back muscles used to support posture. This activity should always be carried out with someone else present as there is a risk of falling. • Lie as flat as possible on the bed for 20-30 minutes each day. This exercise allows for a good stretch and gives the neck muscles a chance to relax. • Stand up and move regularly. Moving regularly helps to keep leg muscles strong and maintain good balance. Factsheet: Exercise and physical activity for people with dementia , Alzheimer’s
  58. 58. Time Duration for Exercise in late Stages • People in the later stages of dementia should be encouraged to move about regularly and change chairs, for example, when having a drink or a meal. • There should be opportunities to sit unsupported (as far as possible) with supervision on a daily basis. • A daily routine involving moving around the home can help to maintain muscle strength and joint flexibility. • People in the later stages of dementia should be encouraged to move about regularly and change chairs, for example, when having a drink or a meal. • There should be opportunities to sit unsupported (as far as possible) with supervision on a daily basis. • A daily routine involving moving around the home can help to maintain muscle strength and joint flexibility. Factsheet: Exercise and physical activity for people with dementia , Alzheimer’s Society
  59. 59. Benefits… • improving physical function - maintaining muscle strength and joint flexibility can be a way of helping people maintain independence for longer • helping to keep bones strong and reducing the risk of osteoporosis (a disease that affects the bones, making them weak and more likely to break) • improved cognition - recent studies have shown that exercise may improve memory and slow down mental decline • improving sleep • opportunities for social interaction and reducing the feeling of isolation • reducing the risk of falls - physical activity can improve strength and balance, and help to counteract the fear of falling • enhanced confidence about the body and its capabilities - through improved body image and a sense of achievement. • improving physical function - maintaining muscle strength and joint flexibility can be a way of helping people maintain independence for longer • helping to keep bones strong and reducing the risk of osteoporosis (a disease that affects the bones, making them weak and more likely to break) • improved cognition - recent studies have shown that exercise may improve memory and slow down mental decline • improving sleep • opportunities for social interaction and reducing the feeling of isolation • reducing the risk of falls - physical activity can improve strength and balance, and help to counteract the fear of falling • enhanced confidence about the body and its capabilities - through improved body image and a sense of achievement. Factsheet: Exercise and physical activity for people with dementia , Alzheimer’s
  60. 60. Evidences…. • Eggermont et al.’s (2006) review includes a wider range of trials which shows that, though a number of studies found that exercise improved affective and functional outcomes, the overall strength of this conclusion is limited by inconsistencies among trials. • Some studies are giving consistent evidence that exercise programs can improve sleep in persons with dementia. • The reviewers posited that exercise activities that included walking were more likely to have a positive effect on mood compared to interventions without, and that frequent exercise sessions were more likely to lead to improvements in sleep compared to more sporadic sessions. • Interventions of longer duration may have a benefit on functional ability in dementia patients. • Eggermont et al.’s (2006) review includes a wider range of trials which shows that, though a number of studies found that exercise improved affective and functional outcomes, the overall strength of this conclusion is limited by inconsistencies among trials. • Some studies are giving consistent evidence that exercise programs can improve sleep in persons with dementia. • The reviewers posited that exercise activities that included walking were more likely to have a positive effect on mood compared to interventions without, and that frequent exercise sessions were more likely to lead to improvements in sleep compared to more sporadic sessions. • Interventions of longer duration may have a benefit on functional ability in dementia patients.
  61. 61. Wandering-Definition • “A tendency to move about either in a seemingly aimless or disoriented fashion, or in pursuit of an indefinable or unobtainable goal.” (Stokes) • “Frequent and/or unpredictable pacing with no discernible goal.” (Dawson) • “Wanderers are patients with navigational difficulties.” (de Leon) • “A tendency to move about either in a seemingly aimless or disoriented fashion, or in pursuit of an indefinable or unobtainable goal.” (Stokes) • “Frequent and/or unpredictable pacing with no discernible goal.” (Dawson) • “Wanderers are patients with navigational difficulties.” (de Leon) Hope & Fairburn (1990)
  62. 62. Situations leading to wandering • The person walks about their environment and cannot find his/her way back. • The caregiver briefly leaves the individual alone while doing something else in the house and the person with dementia inexplicably gets up and leaves the home and then cannot find their way back. • The person feels confused or disoriented in the environment. • When the environment is threatening or over stimulating, the person may be agitated or simply wanting to search for a safer, calmer, or familiar environment. • The person has excess energy or is bored. • The person is in pain. • The person walks about their environment and cannot find his/her way back. • The caregiver briefly leaves the individual alone while doing something else in the house and the person with dementia inexplicably gets up and leaves the home and then cannot find their way back. • The person feels confused or disoriented in the environment. • When the environment is threatening or over stimulating, the person may be agitated or simply wanting to search for a safer, calmer, or familiar environment. • The person has excess energy or is bored. • The person is in pain.
  63. 63. How to deal with wandering??  Structured day: – Structuring the activities of the day keeps the patient busy and is helpful in prevention of wandering. – Studies also report that structuring also improve cognition in patients with dementia. – With help from the occupational therapy healer, a programme of daily activities is devised. – Unfortunately, the dementing patient has a limited attention span, so this does not keep them occupied for very long. – Provision of interest, exercise and companionship may prevent wandering [Stokes (1988)].  Exercise: – whenever possible, staff should take patients for a walk around the hospital and the grounds, but we find the wanderers, who have seemingly limitless energy, are off wandering again the minute they are back on the unit.  Structured day: – Structuring the activities of the day keeps the patient busy and is helpful in prevention of wandering. – Studies also report that structuring also improve cognition in patients with dementia. – With help from the occupational therapy healer, a programme of daily activities is devised. – Unfortunately, the dementing patient has a limited attention span, so this does not keep them occupied for very long. – Provision of interest, exercise and companionship may prevent wandering [Stokes (1988)].  Exercise: – whenever possible, staff should take patients for a walk around the hospital and the grounds, but we find the wanderers, who have seemingly limitless energy, are off wandering again the minute they are back on the unit.
  64. 64. How to deal with wandering? • Distraction: the aim is to the dementing patient to forget his/her intention to wander and divert them to another activity. • Collusion: accompanying the wanderer, who is usually searching for someone or something, until the situation is diffused. • Use of mirrors (Mayer & Darby, 1991): The mirrors work quite well in reducing exiting. – Patients talk to their reflection, gazing into mirror for periods of time, using it appropriately to check appearance, walking around the mirror and moving the mirror, thus distracting them from their original intent of exiting. • Distraction: the aim is to the dementing patient to forget his/her intention to wander and divert them to another activity. • Collusion: accompanying the wanderer, who is usually searching for someone or something, until the situation is diffused. • Use of mirrors (Mayer & Darby, 1991): The mirrors work quite well in reducing exiting. – Patients talk to their reflection, gazing into mirror for periods of time, using it appropriately to check appearance, walking around the mirror and moving the mirror, thus distracting them from their original intent of exiting.
  65. 65. How to deal with wandering? • Visual Barriers (Namazi et al, 1989): visual barriers to hide exit also reduce the wandering. • Detour door-keeping: – Keep the detour across the open doorway in the corridor where the patients’ exit from and found it significantly reduced exiting. – Of the approaches monitored, patients would walk up to the detour, simply turn around and walk back onto the unit, or touch it and then turn round and walk back onto the unit. (A detour or diversion route is a route around a planned area of prohibited or reduced access.) • Use of music • Visual Barriers (Namazi et al, 1989): visual barriers to hide exit also reduce the wandering. • Detour door-keeping: – Keep the detour across the open doorway in the corridor where the patients’ exit from and found it significantly reduced exiting. – Of the approaches monitored, patients would walk up to the detour, simply turn around and walk back onto the unit, or touch it and then turn round and walk back onto the unit. (A detour or diversion route is a route around a planned area of prohibited or reduced access.) • Use of music
  66. 66. Evidences…. • Traditional measures to reduce wandering include drugs, restraints, locked doors, and other barriers; but such interventions can be harmful. • It has been hypothesized that non-pharmacological treatments for wandering may provide safe and ethical alternatives. • One review examined the use of subjective barriers, defined as barriers that appear as an obstruction only to persons with cognitive impairment. – Examples of subjective barriers include mirrors, floor stripes or grids, camouflage of doors or doorknobs, and concealment of view through door windows. • The authors therefore concluded that evidence evaluating the effect of subjective barriers is lacking, and the possibility that such barriers cause psychological harm remains unknown. • Traditional measures to reduce wandering include drugs, restraints, locked doors, and other barriers; but such interventions can be harmful. • It has been hypothesized that non-pharmacological treatments for wandering may provide safe and ethical alternatives. • One review examined the use of subjective barriers, defined as barriers that appear as an obstruction only to persons with cognitive impairment. – Examples of subjective barriers include mirrors, floor stripes or grids, camouflage of doors or doorknobs, and concealment of view through door windows. • The authors therefore concluded that evidence evaluating the effect of subjective barriers is lacking, and the possibility that such barriers cause psychological harm remains unknown. Price JD, Hermans D, Grimley Evans J. Subjective barriers to prevent wandering of cognitively impaired people. Cochrane Database of Systematic Reviews. 2009(3).
  67. 67. Evidences…. • Another Cochrane review sought to examine interventions for wandering of people with dementia in the domestic setting, as opposed to the institutional setting. • Two RCTs conducted in institutional settings determined that exercise and walking therapies had no impact on wandering. • A third systematic review on wandering examined the effectiveness of a variety of non-pharmacological interventions for wandering and included 11 studies (N=594) • Overall, it is inconclusive as to whether multisensory stimulation, exercise, therapeutic touch, aromatherapy, or music therapy has a measurable effect on the behavioral symptoms of wandering associated with dementia. • Another Cochrane review sought to examine interventions for wandering of people with dementia in the domestic setting, as opposed to the institutional setting. • Two RCTs conducted in institutional settings determined that exercise and walking therapies had no impact on wandering. • A third systematic review on wandering examined the effectiveness of a variety of non-pharmacological interventions for wandering and included 11 studies (N=594) • Overall, it is inconclusive as to whether multisensory stimulation, exercise, therapeutic touch, aromatherapy, or music therapy has a measurable effect on the behavioral symptoms of wandering associated with dementia. Hermans D, Htay UH, McShane R. Non-pharmacological interventions for wandering of people with dementia in the domestic setting. Cochrane Database of Systematic Reviews. 2009(3). Robinson L, Hutchings D, Corner L, et al. A systematic literature review of the effectiveness of non- pharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use. Health Technol Assess. Aug 2006;10(26):iii, ix-108.
  68. 68. Evidences…. • A descriptive review of information and communication technology (ICT) devices identified 13 interventions that focused largely on wandering behaviors. • These examples of smart home technologies included – Global Positioning System (GPS) location systems, – boundary alarms activated by wristband, – floor-lighting systems activated upon wandering detection, – communication systems instructing the patient to return to bed after failure to return for a pre-defined period of time, and – alarms alerting the caregiver of wandering behavior. • The settings included residential homes, nursing homes, and hospital settings. • The devices were generally found to be effective, reliable, and successful in detecting wandering, locating lost patients, and reducing patient and caregiver stress. • Uncontrolled studies suggest that GPS location systems for wandering behavior may improve patient safety. • A descriptive review of information and communication technology (ICT) devices identified 13 interventions that focused largely on wandering behaviors. • These examples of smart home technologies included – Global Positioning System (GPS) location systems, – boundary alarms activated by wristband, – floor-lighting systems activated upon wandering detection, – communication systems instructing the patient to return to bed after failure to return for a pre-defined period of time, and – alarms alerting the caregiver of wandering behavior. • The settings included residential homes, nursing homes, and hospital settings. • The devices were generally found to be effective, reliable, and successful in detecting wandering, locating lost patients, and reducing patient and caregiver stress. • Uncontrolled studies suggest that GPS location systems for wandering behavior may improve patient safety. Lauriks S, Reinersmann A, Van der Roest HG, et al. Review of ICT-based services for identified unmet needs in people with dementia. Ageing Res Rev. Oct 2007;6(3):223-246.
  69. 69. Agitation in Dementia • Is a Behavioural symptom – Defined as : “Inappropriate verbal, vocal or motor activity that is not judged by an outside observer to be an obvious outcome of the needs or confusion of the individual” - Cohen-Mansfield & Billing, 1986 • Is a Behavioural symptom – Defined as : “Inappropriate verbal, vocal or motor activity that is not judged by an outside observer to be an obvious outcome of the needs or confusion of the individual” - Cohen-Mansfield & Billing, 1986
  70. 70. Managing Agitation in Dementia • General Management principles : – Prevention is more rewarding than treatment – Non –pharmacological managements are often required than pharmacological – Understand the nature of agitation – Identify provoked and unprovoked agitation – Link agitation with its cause – non- psychiatric, psychiatric, non-cognitive, cognitive – Identify correlates of agitation • General Management principles : – Prevention is more rewarding than treatment – Non –pharmacological managements are often required than pharmacological – Understand the nature of agitation – Identify provoked and unprovoked agitation – Link agitation with its cause – non- psychiatric, psychiatric, non-cognitive, cognitive – Identify correlates of agitation
  71. 71. General Approach to New/Upsetting Behaviors • Check for underlying causes: – Unmet needs (toileting, hunger, thirst etc) – Pain – Delirium (meds, infection) – Constipation, Retention • Reverse/Treat underlying causes. • Check for underlying causes: – Unmet needs (toileting, hunger, thirst etc) – Pain – Delirium (meds, infection) – Constipation, Retention • Reverse/Treat underlying causes.
  72. 72. • Be aware of the persons functional abilities. • Check your communication style: – Speak slowly, clearly, respectfully. – Use simple instructions, one step at a time. – Watch your body language/their body language. – Remind the pts to use their hearing aids, glasses. • Be aware of the persons functional abilities. • Check your communication style: – Speak slowly, clearly, respectfully. – Use simple instructions, one step at a time. – Watch your body language/their body language. – Remind the pts to use their hearing aids, glasses.
  73. 73. ABC’s of General Behavioral Interventions • A-Antecedent: – what was happening before the incident or behavior occurred? Who was there? What were the circumstances? • B-Behavior: – What, when, where? What (be specific) happened? How long did it last? When did it happen? Where did it occur? • C- Consequence: -- the response to behavior. – What happened? Who did what to whom? – Very important to document both successful and unsuccessful interventions. – What, when, where? What (be specific) happened? How long did it last? When did it happen? Where did it occur? • A-Antecedent: – what was happening before the incident or behavior occurred? Who was there? What were the circumstances? • B-Behavior: – What, when, where? What (be specific) happened? How long did it last? When did it happen? Where did it occur? • C- Consequence: -- the response to behavior. – What happened? Who did what to whom? – Very important to document both successful and unsuccessful interventions. – What, when, where? What (be specific) happened? How long did it last? When did it happen? Where did it occur?
  74. 74. Evidences…. • The review identified 14 randomized trials (combined number of subjects=586) that included six types of intervention: – sensory interventions, – social contact, – environmental modification, – caregiver training, – combination therapy, and – behavior therapy • Among the seven types of interventions tested in the studies included in the review, sensory interventions (aromatherapy, thermal bath, calming music, and hand massage) were found to be effective. • There were no significant differences in agitation between treatment groups and control groups for caregiver training, combination therapy, and behavioral therapy. • The review identified 14 randomized trials (combined number of subjects=586) that included six types of intervention: – sensory interventions, – social contact, – environmental modification, – caregiver training, – combination therapy, and – behavior therapy • Among the seven types of interventions tested in the studies included in the review, sensory interventions (aromatherapy, thermal bath, calming music, and hand massage) were found to be effective. • There were no significant differences in agitation between treatment groups and control groups for caregiver training, combination therapy, and behavioral therapy. Kong EH, Evans LK, Guevara JP. Nonpharmacological intervention for agitation in dementia: a systematic review and meta-analysis. Aging Ment Health. Jul 2009;13(4):512-520.
  75. 75. Evidences….. • One study documented a randomized, placebo-controlled trial of a systematic individualized intervention designed to target the symptom of agitation. • The authors described a decision tree intervention model designed to target unmet needs in individuals exhibiting agitation; • The intervention was individualized to participants and included a potentially unlimited variety of specific intervention strategies. • The systematic individualized intervention was described as a decision tree model to assist providers and caregivers in identifying unmet needs that could cause behavioral symptoms of dementia, and the individually tailored treatments were left to the discretion of the care professional. • Examples of specific treatments that were implemented included altering the environment for increased familiarity and comfort, engagement in meaningful activities, and using safety devices. • One study documented a randomized, placebo-controlled trial of a systematic individualized intervention designed to target the symptom of agitation. • The authors described a decision tree intervention model designed to target unmet needs in individuals exhibiting agitation; • The intervention was individualized to participants and included a potentially unlimited variety of specific intervention strategies. • The systematic individualized intervention was described as a decision tree model to assist providers and caregivers in identifying unmet needs that could cause behavioral symptoms of dementia, and the individually tailored treatments were left to the discretion of the care professional. • Examples of specific treatments that were implemented included altering the environment for increased familiarity and comfort, engagement in meaningful activities, and using safety devices. Cohen-Mansfield J, Libin A, Marx MS. Nonpharmacological treatment of agitation: a controlled trial of systematic individualized intervention. J Gerontol A Biol Sci Med Sci. Aug 2007;62(8):908-916.
  76. 76. Inappropriate sexual behaviour • Inappropriate sexual behaviours: – Sexual behaviours that are inappropriate in a given environment, cause distress to all those who are involved and impair the care of the patient in that environment. • Hypersexual behaviours: – Behaviours caused by increased sexual drive or libido. They may be inappropriate. • Not all inappropriate sexual behaviours are hypersexual. • Inappropriate sexual behaviours: – Sexual behaviours that are inappropriate in a given environment, cause distress to all those who are involved and impair the care of the patient in that environment. • Hypersexual behaviours: – Behaviours caused by increased sexual drive or libido. They may be inappropriate. • Not all inappropriate sexual behaviours are hypersexual.
  77. 77. Nonpharmacological treatment of ISB • Always involve the caregivers and families in the treatment plan. • If the behaviours are due to certain social cues which are misinterpreted, then modify those cues. • Supportive psychotherapy • Reassurance/psychoeducation • Always involve the caregivers and families in the treatment plan. • If the behaviours are due to certain social cues which are misinterpreted, then modify those cues. • Supportive psychotherapy • Reassurance/psychoeducation
  78. 78. Nonpharmacological treatment of isb Behavioural modifications For public behaviours: • Sensitive explanation of inappropriateness and gentle redirection • Avoid confrontation • Do not ignore these behaviours • Distraction • Single rooms for patients • Avoid inappropriate external cues like over-stimulating television or radio programs. • Modified clothing: trousers which open in the back or are without zippers may be helpful. • Provide adequate social activity. • Encourage family and friends to visit. • Provide simple and repeated explanations of why such behaviours are unacceptable. Behavioural modifications For public behaviours: • Sensitive explanation of inappropriateness and gentle redirection • Avoid confrontation • Do not ignore these behaviours • Distraction • Single rooms for patients • Avoid inappropriate external cues like over-stimulating television or radio programs. • Modified clothing: trousers which open in the back or are without zippers may be helpful. • Provide adequate social activity. • Encourage family and friends to visit. • Provide simple and repeated explanations of why such behaviours are unacceptable.
  79. 79. Evidences….. • There were no systematic reviews that examined the topic of inappropriate sexual behavior among individuals with dementia. • Currently, the effectiveness of non-pharmacological treatments for inappropriate sexual behavior remains unknown. • There were no systematic reviews that examined the topic of inappropriate sexual behavior among individuals with dementia. • Currently, the effectiveness of non-pharmacological treatments for inappropriate sexual behavior remains unknown.
  80. 80. Urinary Incontinence • Definition: Urinary incontinence (UI) is any involuntary leakage of urine. • It is a common and distressing problem, which may have a profound impact on quality of life. • Urinary incontinence almost always results from an underlying treatable medical condition but is under- reported to physicians. • Definition: Urinary incontinence (UI) is any involuntary leakage of urine. • It is a common and distressing problem, which may have a profound impact on quality of life. • Urinary incontinence almost always results from an underlying treatable medical condition but is under- reported to physicians.
  81. 81. Classification of urinary incontinence • Transient incontinence: – It is a reversible kind of incontinence. The treatment is comparatively easy. Usually encountered in acute urinary tract infection, uncontrolled diabetes mellitus or use of diuretics. • Established incontinence: further divided into 4 types: »Urge incontinence »Stress incontinence »Overflow incontinence »Functional incontinence • Transient incontinence: – It is a reversible kind of incontinence. The treatment is comparatively easy. Usually encountered in acute urinary tract infection, uncontrolled diabetes mellitus or use of diuretics. • Established incontinence: further divided into 4 types: »Urge incontinence »Stress incontinence »Overflow incontinence »Functional incontinence
  82. 82. Behavioral Interventions • First line therapy • Simple measures • reduce amount and timing of fluid intake • avoid bladder stimulants such as caffeine, alcohol • avoid using diuretics just before bedtime • make toilet easier to get to – bedside commode if necessary • First line therapy • Simple measures • reduce amount and timing of fluid intake • avoid bladder stimulants such as caffeine, alcohol • avoid using diuretics just before bedtime • make toilet easier to get to – bedside commode if necessary
  83. 83. Behavioral Interventions  Patient Dependent Behavioral Interventions • Targeted towards mobile, motivated seniors. • Seniors in this population are cognitively able, free from any major physical deficits, and motivated to regain and/or improve their continence. – provided as multi-component interventions including a combination of bladder training techniques, pelvic floor muscle training (PFMT), education on bladder control strategies, and self- monitoring. • Bladder retraining: 20% ‘dry’ rate, 75% of pts with 50% reduction in symptoms • Pelvic muscle (Kegel) exercises: 56 – 95% effective if done about 30 -80 times/day for minimum of 6 weeks • Biofeedback: 54 – 87%  Patient Dependent Behavioral Interventions • Targeted towards mobile, motivated seniors. • Seniors in this population are cognitively able, free from any major physical deficits, and motivated to regain and/or improve their continence. – provided as multi-component interventions including a combination of bladder training techniques, pelvic floor muscle training (PFMT), education on bladder control strategies, and self- monitoring. • Bladder retraining: 20% ‘dry’ rate, 75% of pts with 50% reduction in symptoms • Pelvic muscle (Kegel) exercises: 56 – 95% effective if done about 30 -80 times/day for minimum of 6 weeks • Biofeedback: 54 – 87%
  84. 84. Behavioral Interventions Caregiver Dependent Behavioral Interventions • (also known as toileting assistance) are targeted at medically complex, frail individuals living at home with the assistance of a caregiver, who tends to be a family member. • These seniors may also have cognitive deficits and/or motor deficits. • Scheduled toileting (Timed Voiding) (fixed toilet schedule): 29 – 85% effective • Habit retraining (toileting based on individual pattern): 86% effective • Prompted voiding (given regular opportunities to void) – decreases incontinent episodes  Caregiver Dependent Behavioral Interventions • (also known as toileting assistance) are targeted at medically complex, frail individuals living at home with the assistance of a caregiver, who tends to be a family member. • These seniors may also have cognitive deficits and/or motor deficits. • Scheduled toileting (Timed Voiding) (fixed toilet schedule): 29 – 85% effective • Habit retraining (toileting based on individual pattern): 86% effective • Prompted voiding (given regular opportunities to void) – decreases incontinent episodes
  85. 85. Evidences….. • There is no evidence of effectiveness for habit retraining (n=1 study) and timed voiding (n=1 study). • Prompted voiding may be effective, but effectiveness is difficult to substantiate because of an inadequately powered study (n=1 study) • Multi-component behavioral interventions Include a combination of Bladder training PFMT (with or without biofeedback)Bladder control strategies, Education, Self-monitoring which shows significant reduction in the mean number of incontinent episodes per week and significant improvement in patient's perception of UI • PFMT alone results in significant reduction in the mean number of incontinent episodes per week • There is no evidence of effectiveness for habit retraining (n=1 study) and timed voiding (n=1 study). • Prompted voiding may be effective, but effectiveness is difficult to substantiate because of an inadequately powered study (n=1 study) • Multi-component behavioral interventions Include a combination of Bladder training PFMT (with or without biofeedback)Bladder control strategies, Education, Self-monitoring which shows significant reduction in the mean number of incontinent episodes per week and significant improvement in patient's perception of UI • PFMT alone results in significant reduction in the mean number of incontinent episodes per week Health Quality Ontario. Behavioural interventions for urinary incontinence in community-dwelling seniors: an evidence-based analysis. Ont Health Technol Assess Ser 2008;8(3):1-52. Epub 2008 Oct 1.
  86. 86. Environmental Modifications Getting in and out of the home due to forgetfulness, changes in visual perception (i.e., depth perception and contrast sensitivity) and in gait and balance IDEAS: Innovative Designs in Environments for an Aging Society
  87. 87. Increase lighting & visual contrast to ensure safety (in ambulation) and maintain independence Increase lighting & visual contrast to ensure safety (in ambulation) and maintain independence Place lighting fixtures to maximize illumination and prevent dark areas Use timers or motion sensors to automatically turn lights & lamps on/off Provide access to lighting (switch/lamp) within reach of doorway/exit path Use fluorescent or halogen lighting Use fluorescent/low watt bulbs with motion sensor lights at night to give eyes time to adjust Increase lighting luminance to enable caregiver to provide assistance with mobility Add lamps in rooms Use compact fluorescent bulbs to prevent burns/decrease glare Use light colored lamp shades Use rocker or push switches on lamps High Supervision High Autonomy
  88. 88. Add assistive features or eliminate level changes to ensure safety and maintain independence Add assistive features or eliminate level changes to ensure safety and maintain independence Keep stairs in good repair & free of debris Create level entrance Use porch or deck for access to outdoors Increase contrast on stair edges with paint or reflective tape Install a ramp or lift Install gate on porch steps Install rails on both sides that extend beyond top and bottom step/ ramp Re-grade to create a sloping walk Use alternate entry with fewer or no steps Install a portable ramp Plan for possibility of individual not being able to use steps such as building deck or porch at main level High Autonomy High Supervision
  89. 89. Add assistive features or remove obstacles at doors to ensure safety and maintain independence Add assistive features or remove obstacles at doors to ensure safety and maintain independence Remove clutter from path (e.g., hoses, cords, rugs, flower pots, furniture) Install kick plates on doors Install automatic/power assisted doors Trim shrubs to keep path clear of foliage Replace heavy doors with lightweight ones Widen doorways to accommodate mobility aid or caregivers assisting mobility Provide places to sit and rest (e.g., porch bench) Use a power assisted door Use swing away hinges on doors User lever handles Use remote control for power door opener Rearrange furniture to increase space at doorways for caregiver assist with mobility and accommodate mobility aid Remove screen doors to simplify task Remove steps and high thresholds to eliminate changes in level High Autonomy High Supervision
  90. 90. Use prompts/reminders at doors to maximize orientation and maintain independence Use prompts/reminders at doors to maximize orientation and maintain independence Keep keys in door or attach to string tied to door knob Paint/stain door or doorframe to contrast with wall Reminder note to open/close door • Lever handles with directions (e.g., “push down to open”) Label entrances Use redundant cues such as sounds to attract attention, or multiple signs or objects Place chair next to door High Autonomy High Supervision
  91. 91. Therapeutic garden • SENSORY GARDEN (fines herbes, flowers, etc.) • Appréciation of nature and outdoors • Inviting space (members participated in the design of the therapeutic garden) • Memories of their past can be recalled • SENSORY GARDEN (fines herbes, flowers, etc.) • Appréciation of nature and outdoors • Inviting space (members participated in the design of the therapeutic garden) • Memories of their past can be recalled
  92. 92. Walking path • E-B Principles –Walking Path • Straight connection between common space • Day light at the end of the corridor, helps in way finding • Destination or event at the end of the corridor, no dead end • Photographs with a theme as wall hangings for orientation • Floor materials different for different areas of the building non-glare floor • E-B Principles –Walking Path • Straight connection between common space • Day light at the end of the corridor, helps in way finding • Destination or event at the end of the corridor, no dead end • Photographs with a theme as wall hangings for orientation • Floor materials different for different areas of the building non-glare floor
  93. 93. 93 E-B Principles Environment as a Behavior Regulator Each common space is clear in its meaning, dining area, living area, bedroom  There is no mistaking the identity E-B Principles Environment as a Behavior Regulator Each common space is clear in its meaning, dining area, living area, bedroom  There is no mistaking the identity
  94. 94. 94 Camouflage alarm
  95. 95. 95 Garden access and security - Garden adjacent - Lock on ramp entrance - Lock on gate - Garden can be surveyed - Planters, activity areas - Walking path (figure of 8) Garden access and security - Garden adjacent - Lock on ramp entrance - Lock on gate - Garden can be surveyed - Planters, activity areas - Walking path (figure of 8) E-B Principles
  96. 96. 96 Therapeutic garden
  97. 97. THE END Thanks
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