Feasibility, Acceptability, and Preliminary Efficacy of Dignity Therapy in Patients With Early Stage Dementia and Their Family. A Pilot Randomized Controlled Trial.

Purpose: Dementia is the major cause for disability and dependence in older people and associated with considerable psychological burden. The aim of this study was to determine the feasibility, acceptability and preliminary efficacy of Dignity Therapy, a brief psychotherapeutic intervention to enhance dignity and reduce psychological burden, in patients with early stage dementia and in their families or close friends. Materials and methods: In this randomized, waitinglist-controlled clinical trial a total of 54 patients with new diagnosis of early stage dementia and 54 study partners (spouses: n = 37; relatives: n = 14; close friends: n = 3) were randomly assigned to immediate treatment (n = 28) or delayed treatment (n = 26) after 3 months waiting. The main outcomes were feasibility: proportion of screened and invited patients who consented participation; Acceptability: number of drop-outs, and satisfaction with treatment; Efficacy: psychological burden (Hospital Anxiety and Depression Scale-HADS), quality of life (WHOQOL-Bref), and sense of dignity (Patient Dignity Inventory-PDI). Results: In total 38.6% of all eligible patients (n = 140) consented and were enrolled. Along the study six participants (11.1%) dropped out. Patients' satisfaction with the treatment was high and with no significant difference between the groups. HADS scores were significantly lower in both groups at the 3-months follow-up (immediate group: mean difference = -2.69, SE = 0.85, P = 0.003; delayed group: mean difference = -1.97, SE = 0.89, P = 0.031). There was no significant group by time interaction effect (F = 0.71; df = 2, 70.3; P = 0.50). PDI scores only decreased significantly (i.e., improvement of dignity) in the immediate group (mean difference = -6.56, SE = 1.63, P < 0.001; delayed group: mean difference = -3.01, SE = 1.69, P = 0.081), but the group by time interaction effect was not statistically significant (F = 2.29; df = 1, 46.8; P = 0.14). Quality of life improved in some respects by the treatment, but the immediate and the delayed group did not differ significantly over time. After pooling patients' data of both groups, Dignity Therapy resulted in significant improvements in almost all outcome measures. Patients' family members/close friends reported high satisfaction with the intervention. Conclusions: Our findings suggest that Dignity Therapy is feasible and highly accepted in patients with early stage dementia. Patients reported significant improvements, however, there was no significant effect of the intervention in the immediate treatment group compared to the delayed group.

Use it or lose it! Cognitive activity as a protec-tive factor for cognitive decline associated with Alzheimer's disease.

Because of the worldwide aging of populations, Alzheimer's disease and other dementias constitute a devastating experience for patients and families as well as a major social and economic burden for both healthcare systems and society. Multiple potentially modifiable cardiovascular and lifestyle risk factors have been associated with this disease. Thus, modifying these risk factors and identifying protective factors represent important strategies to prevent and delay disease onset and to decrease the social burden. Based on the cognitive reserve hypothesis, evidence from epidemiological studies shows that low education and cognitive inactivity constitute major risk factors for dementia. This indicates that a cognitively active lifestyle may protect against cognitive decline or delay the onset of dementia. We describe a newly developed preventive programme, based on this evidence, to stimulate and increase cognitive activity in older adults at risk for cognitive decline. This programme, called "BrainCoach", includes the technique of "motivational interviewing" to foster behaviour change. If the planned feasibility study is successful, we propose to add BrainCoach as a module to the already existing "Health Coaching" programme, a Swiss preventive programme to address multiple risk factors in primary care.

[Disclosing the diagnosis and guidance]. / Diagnoseeröffnung und Begleitung.

Before the disclosure of the diagnosis, both the patients with dementia and their relatives experience a long time not only full of insecurity, uncertainty, fear and misgivings but also of conflicts. The beginning of a neurodegenerative disease is always associated with a lot of open questions. If young patients are still active in their professional life, already the stage of "Mild Cognitive Impairment" will cause mistakes, burnout, mobbing, depression and sick leaves. In the partner relationship conflicts and accusations may emerge. It is far too little recognized that those problems at the relational level are often more burdening than the typical deficiencies due to dementia. Unfortunately, it is still considered that a clarification and diagnosis are only worthwhile for diseases which are curable. However, the aim of every evidence-based medicine should be giving every patient and his relatives the best possible quality of life, including symptomatic treatment options and prevention of possible complications. A frank opening discussion of the diagnosis paves the way for the patient and his relatives to deal with the situation and to develop together a solution strategy in the challenging setting of dementia, which always affects the whole familial and social system. The patient is entitled to be informed about his/her diagnosis, including dementia. The diagnostic disclosure requires time and highest professionalism, the knowledge of the individual deficiencies and resources, the social situation, the biography and the personality of the patients but also of their relatives. The diagnostic disclosure arouses a lot of emotions, that need to be addressed and also be absorbed. Primarily, the conversation should be conducted with the patient, but preferably in the presence of the relatives. A very important point is the appreciation of the dementia patient, even with anosognosia. The relatives should not be given just general advice, there should rather be a therapeutic conversation responding to their sensation of permanent loss of the beloved person, their grief and anger. Only this way a solid fundament can be established for mutually finding a cooperative strategy in terms of a behavior-oriented systematic therapy. Therefore, the support of a patient with dementia and his relatives not only involves case management and expert advice, even though they are of great importance too, but also the commitment to the changed relationship and situation. After that, resilience might be developed, which is crucial to cope with this long-lasting disease, which is always associated with a step-by-step farewell.

[Recommendations for diagnosis and therapy of behavioral and psychological symptoms in dementia (BPSD)]. / Empfehlungen zur Diagnostik und Therapie der behavioralen und psychologischen Symptome der Demenz (BPSD).

In patients with dementia, Behavioral and Psychological Symptoms of Dementia (BPSD) are frequent findings that accompany deficits caused by cognitive impairment and thus complicate diagnostics, therapy and care. BPSD are a burden both for affected individuals as well as care-givers, and represent a significant challenge for therapy of a patient population with high degree of multi-morbidity. The goal of this therapy-guideline issued by swiss professional associations is to present guidance regarding therapy of BPSD as attendant symptoms in dementia, based on evidence as well as clinical experience. Here it appears to be of particular importance to take into account professional experience, as at this point for most therapeutic options no sufficiently controlled clinical trials are available. A critical discussion of pharmaco-therapeutic intervention is necessary, as this patient-population is particularly vulnerable for medication side-effects. Finally, a particular emphasis is placed on incorporating and systematically reporting psycho-social and nursing options therapeutic intervention.

Outre les déficits cognitifs, les patients atteints de démences présentent aussi différents symptômes comportementaux et psychologiques de la démence (SCPD) qui rendent le diagnostic, la thérapie et la prise en charge plus difficiles. Ces symptômes ont des conséquences graves pour les patients et leurs proches aidants. Compte tenu de la multimorbidité présente chez beaucoup des patients atteints d'une démence, les SCPD sont souvent difficiles à traiter. L'objectif de ces recommandations appuyées sur l'évidence publiée et l'expérience clinique des experts des Sociétés Professionnelles Suisses est d'apporter un soutien pour la prise en charge des symptômes accompagnant les démences. Accorder une place à l'expérience clinique est d'autant plus important qu'à présent, il n'y a pas suffisamment d'études contrôlées pour la plupart des thérapies utilisées. Une évaluation critique des interventions pharmacothérapeutiques est nécessaire et, compte tenu de possibles effets indésirables, les médicaments doivent être utilisés avec grande précaution dans cette population particulièrement vulnérable. Les possibilités d'interventions psychosociales et les approches en soins sont également considérées et présentées de façon systématique.