Nonpharmacological therapy for the management of neuropsychiatric symptoms of Alzheimer's disease: linking evidence to practice.

BACKGROUND: Behavioral and psychiatric symptoms of dementia affect up to 90% of all patients at some point during their dementing illness. Today, many of these symptoms are treated with pharmacological therapy alone, incongruent with clinical recommendations. Barriers to the use of nonpharmacological interventions with dementia include a lack of education among caregivers on available options, shortage of time for implementation, lack of education on effects of nonpharmacological therapy, poor staff to resident ratios, and unmodifiable physical environments. AIMS: The purpose of this paper is to explore current literature regarding the implementation of nonpharmacological therapy as an adjunct treatment to manage agitation in dementia, to identify practice discrepancies seen commonly among formal and informal caregivers, and to make recommendations for implementing evidence into practice. METHODS: A systematic review of the literature published between 2009 and 2014 was conducted. Four databases were searched including CINAHL, Pubmed, the Cochrane Library, and PsycInfo. FINDINGS: The most prevalent and substantial conclusion among the 10 studies evaluated is that nonpharmacological therapy is safe and effective. Although not every study was able to show statistically significant outcomes when compared to controls, all studies demonstrated a positive trend toward decreasing agitation without any adverse side effects. LINKING EVIDENCE TO ACTION: A multicomponent caregiver education program focused on evidence-based nonpharmacological strategies for addressing agitation in persons with Alzheimer's disease has the potential to decrease agitation, improve patient outcomes, and increase caregiver satisfaction.

The role of sex differences in depression in pathologically defined Alzheimer's disease.

Introduction: Sex differences in Alzheimer's disease (AD) may contribute to disease heterogeneity and affect prevalence, risk factors, disease trajectories and outcomes. Depression impacts a large number of patients with AD and has been reported to be more prevalent in women. We aimed to better understand the interaction between sex, depression and AD neuropathology, which could have implications for detection of symptoms, earlier diagnosis, therapeutic management, and enhanced quality of life. Methods: We compared 338 cases with clinicopathologically confirmed AD (46% women) to 258 control cases (50% women), without dementia, parkinsonism or a significant pathological diagnosis. Depression was assessed both, using the Hamilton Depression Scale (HAM-D), and as being reported in their medical history combined with treatment with antidepressant medication. Results: In the control group, women showed a higher depression severity, and a higher proportion of women were found to meet the cut-off score for depression on the HAM-D (32 vs. 16%) and having an history of depression (33 vs. 21%), while these sex differences were not observed in AD. Further, in both groups, female sex independently predicted the presence of depression, with covariates for age and cognitive status. AD subjects had higher mean HAM-D scores, were more likely to meet cutoff scores for depression (41 vs. 24%) and have a history of depression than controls (47 vs. 27%). When comparing the increase in frequency of depression in controls versus AD, the difference was significantly greater in men (AD men - control men: 24%) than in women (AD women - control women: 9%). Although subjects with depression were more likely to have higher levels of AD neuropathology, these differences were not observed when investigating the control or AD group separately. Discussion: Control women had a higher likelihood and severity of depression than control men, but this sex difference was not noted when considering only those with pathologically defined AD, emphasizing the importance of considering sex in aging studies. AD was associated with higher rates of depression and men may be more likely to report or be diagnosed with depression once they develop AD indicating the importance of more frequent depression screenings in men.

Effect of Relocation on Neuropsychiatric Symptoms in Elderly Adults Living in Long-Term Care.

OBJECTIVES: To determine the evolution of behavioral and psychiatric symptoms of dementia (BPSD) in nursing home (NH) residents after an environmental change through a relocation to a more architecturally suitable facility, while conserving the same medical staff. DESIGN: Prospective, single arm study. SETTING: Long-term care unit. PARTICIPANTS: NH residents (N=116; median age 82.3, range 75.5-89.2; median Neuropsychiatric Inventory for the Nursing Home (NPI/NH) score 22, range 11-34.5; 66.3% female), of whom 102 lived in regular units and 14 in specialized care units (SCUs). MEASUREMENTS: Neuropsychiatric symptoms were evaluated as part of a comprehensive geriatric assessment for each resident 1 week before the relocation and 3 times after the relocation (1, 4, 12 weeks) using the NPI/NH. RESULTS: A mixed-effect linear model found no significant change in global NPI/NH score in the regular unit and a significant decrease in overall NPI/NH score 4 weeks after relocation in the SCUs (ß-coefficient for time by SCU=-11.5, 95% confidence interval (CI)=-17.9-5.2, p < .001), reaching a total decrease of 13 points by 12 weeks after relocation (ß-coefficient for time by SCU=-12.8, 95% CI=-19.1-6.4, p < .001). A statistically significant decrease of 3 points for disinhibition, apathy, and agitation accompanied the NPI/NH score in the secured unit. An increase of 3 points in aberrant motor behavior was seen by 12 weeks after relocation in the SCU. CONCLUSION: Relocation to an architecturally different facility significantly reduced BPSD of NH residents 1 month after relocation. J Am Geriatr Soc 66:2183-2187, 2018.

Non-pharmacological treatment reducing not only behavioral symptoms, but also psychotic symptoms of older adults with dementia: a prospective cohort study in Taiwan.

AIM: The clinical effectiveness of non-pharmacological interventions on behavioral and psychological symptoms of dementia (BPSD) among older Chinese with dementia remains unclear, and the evidence supporting the benefits of a non-pharmacological approach on psychotic symptoms is scarce. METHODS: A prospective cohort study including 104 older men with dementia living in two veterans homes in Taiwan was carried out in 2011. An organized program of music therapy, orientation training, art-cognitive activities and physical activities was carried out for the intervention group. All participants were evaluated for neuropsychiatric inventory (NPI), defined daily dose of psychotropic drug use, Barthel Index, Instrumental Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale, Tinetti balance score and Tinetti gait score. RESULTS: Overall, 104 residents were enrolled and 92 of them completed the study. The intervention group had a more significant reduction than the reference group in the overall NPI score (-2.36, P = 0.046), and in the subcategories of delusion (-0.9, P = 0.018), hallucination (-0.82, P = 0.004) and agitation (-0.91, P = 0.038). Multivariate analysis showed that the non-pharmacological intervention was associated with a favorable outcome in overall NPI score (OR 4.113, P = 0.013) and in the subcategories of hallucination (OR 14.309, P = 0.049) and agitation (OR 6.604, P = 0.037). Meanwhile, a higher baseline NPI score was also associated with a favorable outcome in overall NPI score, and in the subcategories of delusion, hallucination and agitation. CONCLUSION: Non-pharmacological interventions have a positive effect on behavioral and psychological symptoms of dementia, not only in outward symptoms like agitation, but also intrinsic psychotic symptoms like hallucination and delusion, and agitation in older Chinese men with dementia.

Radio electric asymmetric brain stimulation in the treatment of behavioral and psychiatric symptoms in Alzheimer disease.

PURPOSE: Behavioral and psychiatric symptoms of dementia (BPSD) are common in Alzheimer's disease (AD) and disrupt the effective management of AD patients. The present study explores the use of radio electric asymmetric brain stimulation (REAC) in patients who have had a poor response to pharmacological treatment. PATIENTS AND METHODS: Eight patients (five females and three males; mean [±standard deviation] age at study baseline: 69.9 ± 3.0 years) diagnosed with AD according to the DSM-IV-TR criteria (mean onset age of AD: 65.4 ± 3.5 years) were cognitively and psychometrically assessed with the Mini-Mental State Examination (MMSE), the Activity of Daily Living (ADL), the Instrumental Activity of Daily Living (IADL), and the Neuropsychiatric Inventory (NPI), prior to and after each of 2 REAC treatment cycles. RESULTS: Scores on the MMSE and all subscales of the NPI (frequency, severity, and distress), the ADL, and the IADL were significantly improved following the initial REAC treatment. There was further significant improvement in all measurements (with a tendency for improvement in the IADL) after the second REAC treatment cycle. CONCLUSION: The improvement of cognitive and behavioral/psychiatric functioning following REAC treatment suggests that this innovative approach may be an effective, safe, and tolerable alternative to pharmacological treatment of AD patients, especially in the area of BPSD. Elderly patients suffering from other types of dementia may also benefit from REAC treatment.