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. 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. 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. 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. 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Withdrawn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. 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• Withdrawn, apathetic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. 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. 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. 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
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. 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. 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. 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.
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. 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. 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. 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. 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. 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. 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. 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. 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. 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;
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. 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. 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.
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.
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.
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. 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. 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.
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.
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. 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. 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. 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. 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. 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. Types of Animals
• There are many different types of therapy
animals
• Most common are dogs, cats, & horses
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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
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
