Individualized Cognition-Action intervention to prevent behavioral disturbances and functional decline in institutionalized older adults: a randomized pilot trial.

OBJECTIVE: To evaluate the effectiveness of an individualized Cognition-Action (CA) intervention to reduce behavioral disturbances in severely deconditioned institutionalized old adults. DESIGN: 12 weeks randomized pilot trial of either individualized Cognition-Action program (n = 24) or routine medical care as control (C, n = 25). SETTING: Long-term care (LTC) of the Geriatric Department from the University State Hospital in Bordeaux, France. PARTICIPANTS: 49 institutionalized old patients with at least one Neuropsychiatric symptoms > or =4. INTERVENTION: The CA rationale was a non-preconceived ideas approach over the patient's abilities and discourse. Patients received short bouts of 5-15 min and accumulated 50 min of interaction per week. CA intervention used five standardized exercises as tools to enhance communication and social interactions. CA was compared to usual care. MEASUREMENTS: Primary outcomes were the Neuropsychiatric inventory (NPI) total and symptoms scores. Secondary outcomes were the BERG balance scale, the Geriatric Depression Scale (GDS), Quality of life AM-PAC-CAT and Muscle strength. RESULTS: The CA group had a clinically significant NPI total score reduction compared to C, -7, 95%CI [-10.8 to -3], eta2 = 0.24. CA group showed a risk reduction of NPI total score worsening, OR = 0.09, 95%CI [0.02-0.37]. BERG total score was clinically improved in the CA group compared to C, 4.9 95%CI [0.7-9.2], eta2(p)= 0.11. CA patients reduced their GDS score and improved their Quality of life and Strength. CONCLUSIONS: The combination of tailored guidance and simple standardized exercises was an effective behavioral management approach for behavioral disturbances reduction and functional autonomy improvement in institutionalized old adult populations.

Pilot study of a 10-week multidisciplinary Tai Chi intervention in sedentary obese women.

OBJECTIVE: Alternative approaches to weight control and physical activity are increasingly needed. Numerous factors influence weight management, including the choice of physical exercise. No study has previously examined the therapeutic effect of a multidisciplinary weight management program incorporating Tai Chi (TC) exercises among sedentary obese women. DESIGN: Randomized intervention trial with blinded medical provider. SETTING: In day hospital consultations. PARTICIPANTS: Twenty-one obese women. INTERVENTION: All subjects participated in a 10-week weight management program that was part of usual care and included a hypocaloric balanced diet, a weekly physician/psychologist/dietician group session, and an exercise program. For the exercise component, subjects were randomized to either a 2-hour weekly session of TC or a conventional structured exercise program. MAIN OUTCOME MEASURES: Changes in weight, body composition, heart rate, blood pressure, mobility scores, mood, Three Factor Eating Questionnaire scores, and General Self-Efficacy. RESULTS: The TC arm improved in resting systolic blood pressure, chair rise test, mood, and reduced percent of fat at week 10 and at 6 months follow-up. General self-efficacy was enhanced in both groups and maintained at 30 weeks. CONCLUSION: The observed benefits over a 30-week period of a multidisciplinary weight management program incorporating TC exercises on physical functioning mood and dietary restraint need further understanding of how sedentary obese women adhere to physical activity like TC or other alternative exercises.

Co-occurrence of neuropsychiatric syndromes in demented and psychotic institutionalized elderly.

OBJECTIVES: To explore and determine the clinical figures of behavioral syndromes from the factor structure of the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) in demented and psychotic patients. SETTING: Two nursing homes and two long-term care homes. DESIGN: Observational, cross-sectional. PARTICIPANTS: One hundred and sixty-three institutionalized elderly with dementia or psychosis (66.9% female), mean age 80.9 +/- 9.1 years. MEASUREMENTS: The NPI-NH includes 12 neuropsychiatric symptoms and a distress scale. The product score of frequency (F) and severity (S) ratings provides an overall score for each of the 12 items. An exploratory principal component analysis with Varimax rotation was performed on the F x S scores according to patients' diagnosis. RESULTS: High internal consistency of the NPI-NH was found (alpha = 0.8). In demented patients a 4-factor solution was found that explained 63.9% of the variance, with the syndromes: (a) 'hyperactivity'; (b) 'affective'; (c) 'psychosis'; and (d) 'Hallucinations'. A four-factor solution was also found in psychotic patients, explaining 61.3% of variance, with syndromes: (a) 'affective'; (b) 'frontal lobe symptoms'; (c) 'sundowning'; and (d) 'psychomotor agitation'. A syndrome was unlikely to appear alone but was most likely to occur with other syndromes. A specific pattern of syndrome co-occurrence were found in demented (a + b + c in 30.5% of cases) and psychotic patients (a + b + c + d in 35.2% of cases). CONCLUSION: The syndrome taxonomies are consistent with the diagnostic criteria. The clinical use of syndrome co-occurrence could help to further understand and evaluate behavioral changes in pharmacological and non-pharmacological treatments.

Are Dementia Patient's Engagement Using Tailored Stimuli the Same? The Apathy Dilemma in Nursing Home Residents.

Background. Apathy is the most frequent behavioural disturbance understanding how apathy drives engagement in resident's activities of interests is a milestone to better understanding and tailored challenging interventions targeting engagement enhancement. Method. Residents aged 60 and older with dementia according to the ICD 10 from four nursing homes in the south east of France. A set of 25 stimuli were used and categorized by participant into Work, Leisure, Family, or Personal categories, an additional "not interested" category was used for comparison of engagement. The participants stimuli allocation was randomized in guided and unguided situations over a two-week period with 15minute interaction for each stimulus (n = 2) of each category (5×(15 min×2)). Clinical trial identifier: NCT01314131. Results. The mean age, 95% confidence interval (CI) of the 40 participants was 85.4 (83.8-87) with a mean MMSE score, CI95% of 17.7 (16.5-19). Analyses revealed a significant superiority effect of guidance over unguided interaction in duration of engagement in all categories of interest except for the stimulus category "family" and all P < .05. Apathetic participants when guided had longer engagement duration in stimulus Leisure and Personal (all P < .01). Conclusion. Guidance and better activities of interest can lead to enhanced engagement time in participants with dementia.

Detection of activities of daily living impairment in Alzheimer's disease and mild cognitive impairment using information and communication technology.

BACKGROUND: One of the key clinical features of Alzheimer's disease (AD) is impairment in daily functioning. Patients with mild cognitive impairment (MCI) also commonly have mild problems performing complex tasks. Information and communication technology (ICT), particularly techniques involving imaging and video processing, is of interest in order to improve assessment. The overall aim of this study is to demonstrate that it is possible using a video monitoring system to obtain a quantifiable assessment of instrumental activities of daily living (IADLs) in AD and in MCI. METHODS: The aim of the study is to propose a daily activity scenario (DAS) score that detects functional impairment using ICTs in AD and MCI compared with normal control group (NC). Sixty-four participants over 65 years old were included: 16 AD matched with 10 NC for protocol 1 (P1) and 19 MCI matched with 19 NC for protocol 2 (P2). Each participant was asked to undertake a set of daily tasks in the setting of a "smart home" equipped with two video cameras and everyday objects for use in activities of daily living (8 IADLs for P1 and 11 for P2, plus 4 temporal execution constraints). The DAS score was then computed from quantitative and qualitative parameters collected from video recordings. RESULTS: In P1, the DAS score differentiated AD (DAS(AD,P1) = 0.47, 95% confidence interval [CI] 0.38-0.56) from NC (DAS(NC,P1) = 0.71, 95% CI 0.68-0.74). In P2, the DAS score differentiated MCI (DAS(MCI,P2) = 0.11, 95% CI 0.05-0.16) and NC (DAS(NC,P2) = 0.36, 95% CI 0.26-0.45). CONCLUSION: In conclusion, this study outlines the interest of a novel tool coming from the ICT world for the assessment of functional impairment in AD and MCI. The derived DAS scores provide a pragmatic, ecological, objective measurement which may improve the prediction of future dementia, be used as an outcome measurement in clinical trials and lead to earlier therapeutic intervention.

Effects of different learning methods for instrumental activities of daily living in patients with Alzheimer's dementia: a pilot study.

We examined whether errorless learning (EL) and learning by modeling (LM) were more advantageous than trial and error learning (TEL) in the acquisition of instrumental activities of daily living (IADL) in Alzheimer's dementia (AD) patients (n = 14). Using a counterbalanced within-subject design, participants performed 3 learning conditions. EL consisted of straightforward prompts before any action, LM focused on the modeling of each step of the tasks and standard TEL without cues was used as a control condition. The participants had to (re)learn 3 IADL. Repeated-measure analyses during learning and follow-up assessments were performed 1 and 3 weeks after learning. The LM and the EL procedures resulted in significantly better learning compared to TEL, with effect sizes (partial eta squared) of 0.42 and 0.35, respectively. This is the first controlled study to show that (re)learning of IADL is possible in patients with AD using an error-reduction approach.

Effects of exercise programs to prevent decline in health-related quality of life in highly deconditioned institutionalized elderly persons: a randomized controlled trial.

BACKGROUND: Our objective was to assess the effects of targeted exercise programs on health-related quality of life compared with usual care based on the ability to perform activities of daily living (ADL) and the Neuropsychiatric Inventory scores in geriatric institutionalized persons. METHODS: A randomized controlled trial of 2 exercise programs vs usual care was conducted in 160 institutionalized persons 65 years or older who were able to understand basic motor commands and to move from one position to another. Interventions were performed over 6 months and were either an adapted tai chi program (4 times 30 min/wk) or a cognition-action program (2 times 30-45 min/wk) that focused primarily on an adapted guidance of patient-centered communication skills. The control group received usual care. The study was conducted at 4 settings. The main outcomes were changes in health-related quality of life based on ADL and Neuropsychiatric Inventory scores after 12 months. RESULTS: The control group experienced a decline in ADL over the 12-month period compared with the adapted tai chi and cognition-action groups, but the differences were not significant (P = .24 and P = .15, respectively). Also, the components of ADL, eg, ability to walk, continence, and nutrition, were maintained better in the intervention groups than in the control group. The total Neuropsychiatric Inventory score also worsened significantly in the control group, while it was unchanged or improved in the intervention groups. The differences between the cognition-action group and the control group were significant (P > .001). Neuropsychiatric diagnosis subgroups (such as dementia and psychosis) did not show a specific response from any intervention. CONCLUSION: Adapted exercise programs can slow down the decline in health-related quality of life among heterogeneous, institutionalized elderly persons. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00623532.