Mean scores on the Mini Mental Status Exam improved 2.7 points for the bright light group and .3 for the dim light group. Here is a chart that compares the light therapy findings with a Rivastigmine trial. In the 26-week trial of Rivastigmine, a cholinesterase inhibitor, scores increased .3 points for those taking 6-12 mg a day while they declined about .3 for those taking 1-4 mg and .79 for the placebo group. Changes in MMSE scores were significant between the high-dose group and placebo. The Rivastigmine trial had 699 subjects with baseline scores between 10 and 26. More than 85% of persons in the treatment groups in the Rivastigmine trial reported at least one adverse event, the most common being nausea. The rivastigmine trial used a prospective, randomized, double-blind, placebo controlled, parallel-group design (Corey-Bloom et al. 1998. International Journal of Geriatric Psychopharmacology). Scores on the Mini Mental Status Exam range from 0 (low cognitive functioning) to 30, high cognitive functioning.
Non-pharmacologic treatment of dementia
Non-pharmacologic management of dementia Marc Evans M. Abat, MD, FPCP, FPCGM Internal Medicine-Geriatric Medicine Clinical Associate Professor, PGH Visiting Consultant, Manila Doctors Hospital Director, Center for Healthy Aging, The Medical City
Side Effects of Cholinesterase Inhibitors• total number of patients who suffered at least one adverse event before the end of treatment• significant differences in favor of placebo• OR 2.51 95%CI 2.14 to 2.95, p<0.00001 Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005593. DOI: 10.1002/14651858.CD005593
Abdominal pain OR 1.95 95%CI 1.46 to 2.61 p<0.00001 7 studiesAbnormal dreams OR 5.38 95%CI 1.34 to 21.55 p=0.02 1 studyAnorexia OR 3.75 95%CI 2.89 to 4.87 p<0.00001 10 studiesAsthenia OR 2.47 95%CI 1.27 to 4.81 p=0.008 3 studiesDiarrhea OR 1.91 95%CI 1.59 to 2.30 p=<0.00001 13 studiesDizziness OR 1.99 95%CI 1.64 to 2.42 p<0.00001 12 studiesFatigue OR 4.39 95%CI 1.21 to 15.85 p=0.02 1 studyHeadache OR 1.56 95%CI 1.27 to 1.91 p<0.0001 9 studiesInsomnia OR 1.49 95%CI 1.12 to 2.00 p=0.007 7 studiesMuscle cramp OR 13.32 95%CI 1.71 to 103.74 p=0.01 1 studyNausea OR 4.87 95%CI 4.13 to 5.74 p<0.00001 13 studiesPeripheral edema OR 2.08 95%CI 1.01 to 4.28 p=0.05 1 studySyncope OR 1.90 95%CI 1.09 to 3.33 p=0.02 5 studiesTremor OR 6.82 95%CI 1.99 to 23.37 p=0.002 2 studiesVertigo OR 3.95 95%CI 1.08 to 14.46 p=0.04 1 studyVomiting OR 4.82 95%CI 3.91 to 5.94 p<0.00001 11 studiesWeight loss OR 2.99 95%CI 1.89 to 4.75 p<0.00001 4 studies Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005593. DOI: 10.1002/14651858.CD005593
• Cost of treatment with ChEI, e.g. donepezil 10 mg per day P192 per tab x 1 tab per day x 30 days = P5760/month Add this to: Cost of living, cost of other medications and treatment
Activities of Daily Living rC v io og ha ni tio Be n
Non-pharmacologic InterventionsSensory Enhancement Social Contact or Relaxation • Pets• Massage/touch • One-on-one• Music interaction• White noise • Simulated interaction,• Aromatherapy family videos• Multisensory modalities, e.g. Snoezelen
Behavior Therapy Structured Activities• Differential • Arts and crafts Reinforcement • Group exercises and• Stimulus Control singing • Outdoor walksCognitive Therapy Environmental InterventionStaff Training • Stimulus control including Wandering prevention • Natural/enhanced environment • Reduced stimulation
Cognitive Rehabilitation and Training• effectiveness and impact of cognitive training and cognitive rehabilitation – improving memory and other aspects of cognitive functioning – early stages of Alzheimer’s disease or vascular dementia• 9 trials included in the review, up to 24 weeks duration of intervention• No significant positive or negative effects Cochrane Database of Systematic Reviews 2003, Issue 4. Art.No.: CD003260. DOI: 10.1002/14651858.CD003260
Reminiscence Therapy• four trials with a total of 144 participants had extractable data• significant for cognition and mood (at follow-up) and on a measure of general behavioural function (at the end of the intervention period) vs. no treatment and social contact control• significant decrease in caregiver strain• staff knowledge of group members’ backgrounds improved significantly• No harmful effects• Need for more robust studies Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001120. DOI: 10.1002/14651858.CD001120.pub2.
• 59 with moderate-to-severe dementia were enrolled in this study.• Randomly assigned; 30 MT sessions (16 wk of treatment); control group received educational support or entertainment activities• NPI total score significantly decreased in the experimental group at 8th, 16th, and 20th weeks (P=0.002).• Specific BPSD significantly improved.• empathetic relationship and the patients active participation in the MT approach, also improved in the experimental group Alzheimer Dis Assoc Disord. 2008 Apr-Jun;22(2):158-62
• 5 studies included for review• Poor quality with heterogenous results• All report favorable outcomes of music on behavior (e.g. wandering), cognitive function and emotional/social functioning Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003477. DOI: 10.1002/14651858.CD003477.pub2.
• Music Therapy Am J Geria Psych 2001; 9:361–381
• Ballard 2002 in an RCT: 10% Lemon Balm in grapeseed soil and base lotion applied topically to arms and face twice daily for 1-2 minutes for 4 weeks vs sunflower oil applied in the same way• 72 people with severe dementia, diagnosed with the Clinical Dementia Rating scale (Hughes 1982) and clinically significant agitation• Improved aggressive and non-aggressive behavior on CMAI, NPI and DCM Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003150. DOI: 10.1002/14651858.CD003150.
• Randomized, controlled trial, ITT analysis of 134 ambulatory patients with mild to severe AD.• Collective exercise program (1 hour, twice weekly of walk, strength, balance, and flexibility training) vs routine medical care for 12 months• slower ADL decline than in exercise vs. routine medical care (12-month mean treatment differences: ADL=0.39, P=.02). No adverse effects of exercise occurred. J Am Geriatr Soc. 2007 Feb;55(2):158-65
• Outdoor walks and other physical activities Am J Geria Psych 2001; 9:361–381
• Hearing aids and removal of restraints Am J Geria Psych 2001; 9:361–381
Why the paucity of “solid” evidence?• Difference in populations and available resources• Differences in protocols• Differences in assessment of outcomes• Inherent nature of the intervention-”blinding” not feasible• Interaction of the intervention with external factors
Then why should we consider non- pharmacologic interventions?• Relative devoid of side effects• Relatively cheaper• Most, if not all, of the small studies were done on patients already on usual care – Cholinesterase inhibitors – Antipsychotics and sedatives – Medical care Any positive effects, no matter how small the sample size, is most likely due to the non-pharmacologic intervention
Zgola’s 7 W’s of a Functional Evaluation• What can the client do?• What does the client do?• How does he or she do it?• Which parts of the task is the client unable to do? and Why?• Where or when does he or she perform best?
Features of a Successful Activity• Simplicity• Time-frame• Distractibility• Creativity• Purposeful and adult like• Scheduling
Summary• Several non-pharmacologic interventions are available for management of dementia• Studies regarding their efficiency are available; however, they are small and heterogenous• The field of study is still open for more rigorous protocols• In the meantime, non-pharmacologic interventions can be used because of some degree of effectiveness, lack of side effects and affordability