It makes sense to define something by what it is rather than by what it is not, Barry Reisberg (New York University Langone Medical Center, USA) argues. Hence the move to encourage use of the term “ecopsychosocial” rather than “non-pharmacological” when describing a comprehensive therapeutic approach to dementia.1
The new term may stretch the mouth a bit. But it needs to be wide if the concept is to encompass the full range of approaches and interventions -- environmental, psychological and social – that, when effectively managed, seems capable of delaying the decline in function that leads to transfer from community care to an institution.
The latest findings were presented by Sunnie Kenowsky, also of the New York University Langone Medical Center.
Patients involved in the recent study had a diagnosis of probable Alzheimer’s Disease (AD) that was moderate to severe and lived in the community. Twenty pairs of people with AD and their carers were randomized, ten each to the experimental and control arms. Assessment was blinded.2
Patients in both groups received an NMDA receptor antagonist and standard care. The additional intervention in the experimental arm consisted of a comprehensive program of home visits and carer education, training and support designed to encourage respect for the person with AD, establishing their needs and preferences, and maintaining their independence.2
The program involved considerable effort but carers found it benefited them as well as those they cared for
Carers were asked to emphasize success and engagement, and to manage difficult behaviors with patience and empathy. Other elements included training in memory coaching and how to encourage exercise involving balance, strength and relaxation.2
Over 28 weeks, comprehensive individualized intervention produced significantly better function compared to the control group. This benefit was evident both on the New York University Clinician's Interview-Based Impression of Change Plus Caregiver Input measure and on the Functional Assessment Staging (FAST-DS) scale.2
Sunnie Kenowsky acknowledged that carers had to put considerable additional effort into adopting the comprehensive program. But, she argued, they soon came to master it, and found that the benefits it brought – such as increased patient skills and independence – made life easier and more pleasant for them as well as those they cared for.
Need to address loneliness and boredom
Around a third of patients with dementia live in nursing or care homes. The session on ecopsychosocial intervention, chaired by Barry Reisberg (principle investigator on the new NYU randomized controlled trial of comprehensive intervention, and lead author on a pivotal 2003 New England Journal paper) also heard about the positive results of patient-centered care in these settings.
Standard dementia nursing in many institutions can involve as little as two minutes of meaningful social interaction every six hours. So there is considerable room for improvement, argued Clive Ballard (University of Exeter School of Medicine, UK).
He and colleagues have conducted a cluster-randomized trial – the Wellbeing and Health for People with Dementia (WHELD) study – which aimed to involve patients in enjoyable activities tailored to individual interests and abilities. Sixteen care homes took part. In the intervention arm, researchers trained “dementia champions” who then led training in their institution.
Compared with controls, patients experiencing enhanced care had higher quality of life, scored less on the Cohen-Mansfield Agitation Inventory, and had reduced care costs – mostly because there was less need to visit Accident and Emergency departments and for hospital admission.
Choral singing in particular transformed patients, so content not just contact is important
Social interaction is the most powerful way of countering loneliness and boredom, Jiska Cohen-Mansfield (Tel Aviv University, Israel) told the meeting.3 Along with colleagues, she has been pioneering group recreational activities in nursing homes. These include choral singing, creative storytelling, baking, reminiscence, and throwing and catching a ball.
Compared with controls, patients involved in the group activities had significantly better social engagement and mood. Choral singing in particular was “transforming”, Professor Cohen-Mansfield said. So the content of the activity is important, not just the social contact. Background noise diminished the benefits of group activities, and for this reason attention should be paid to the layout of homes.
Applying Montessori principles to the creation of person-centered environments for people with dementia was advocated by Cameron Camp, of the Center for Applied Research in Dementia, Ohio, USA. This approach treats Alzheimer’s patients as having disabilities rather than disease, and emphasizes capacities rather than deficits – building on what patients can do with assistance, and encouraging learning by imitation and practice.
A Montessori-based program being developed in Ohio for people with disruptive behaviors has proved valuable in decreasing agitation, wandering and need for medication – while at the same time increasing retention of staff in the homes where it has been introduced.