Group and individual cognitive therapies in Alzheimer's disease: the ETNA3 randomized trial.

BACKGROUND: Although non-drug interventions are widely used in patients with Alzheimer's disease, few large scale randomized trials involving a long-term intervention and several cognitive-oriented approaches have been carried out. ETNA3 trial compares the effect of cognitive training, reminiscence therapy, and an individualized cognitive rehabilitation program in Alzheimer's disease to usual care. METHODS: This is a multicenter (40 French clinical sites) randomized, parallel-group trial, with a two-year follow-up comparing groups receiving standardized programs of cognitive training (group sessions), reminiscence therapy (group sessions), individualized cognitive rehabilitation program (individual sessions), and usual care (reference group). Six hundred fifty-three outpatients with Alzheimer's disease were recruited. The primary efficacy outcome was the rate of survival without moderately severe to severe dementia at two years. Secondary outcomes were cognitive impairment, functional disability, behavioral disturbance, apathy, quality of life, depression, caregiver's burden, and resource utilization. RESULTS: No impact on the primary efficacy measure was evidenced. For the two group interventions (i.e. cognitive training and reminiscence), none of the secondary outcomes differed from usual care. The larger effect was seen with individualized cognitive rehabilitation in which significantly lower functional disability and a six-month delay in institutionalization at two years were evidenced. CONCLUSIONS: These findings challenge current management practices of Alzheimer's patients. While cognitive-oriented group therapies have gained popularity, this trial does not show improvement for the patients. The individualized cognitive rehabilitation intervention provided clinically significant results. Individual interventions should be considered to delay institutionalization in Alzheimer's disease.

[Reinforced accommodation units and the management of patients with dementia]. / Prise en charge des patients déments en unités d'hébergement renforcées.

Dementia is frequently associated with behavioural disorders that can be difficult to manage. In regards to these symptoms, psychoactive drugs are not very effective and have many potential side effects. In order to take care of patients with such severe disorders, specific units called "reinforced hosting units" ("UHR; Unités d'Hébergement Renforcées" in French) have been developed within long term care units. Specifically trained teams take care of these patients in specially designed settings. A French national inquiry has studied the development, the characteristics and the activity of these units in 2013 and 2012.

[Non pharmacologic intervention therapy in Alzheimer's disease]. / Thérapies ambulatoires non médicamenteuses dans les maladies d'Alzheimer.

Actually, no curative treatment is available to fight against Alzheimer's disease. Previous non pharmacologic intervention trials had promising findings. However the lack of scientific validation and standardized modelling restrict their use. Among these techniques, sparing skills therapy (SST) seems promising. This form of care is for patients with early stage of the disease and combines the use of cognitive and functional residual, taking into account the wishes of the patient and their caregiver, the rehabilitation of their environment and the education of the caregiver. The SST is developing in France within specialized teams inside the nursing services at home and is currently the subject of further research.

Non-pharmacological management of behavioural symptoms in nursing homes.

BACKGROUND: Behavioural and psychological symptoms of dementia (BPSD) are often reported in institutions for the elderly. OBJECTIVE: To evaluate the effectiveness of a staff education intervention to manage BPSD in older people with a diagnosis of dementia. METHODS: The trial was conducted in 16 nursing homes; 306 patients with a diagnosis of dementia and presenting BPSD were selected. Nursing homes were randomly allocated to an intervention group or a control group. An 8-week staff education and training programme was conducted in the nursing homes in the intervention group. The main outcome measures were the Cohen-Mansfield Agitation Inventory (CMAI) and an Observation Scale (OS) score. Assessments were done at baseline (W0), at the end of the 'intervention' period (W8) and 12 weeks after (W20). RESULTS: There was a significant decrease in the global CMAI score between baseline and W8 (-7.8; p > 0.01) and between baseline and W20 (-6.5; p > 0.01) in the intervention group but not in the control group. Results of mixed linear models showed that the CMAI global score, the CMAI physically non-aggressive behaviours subscale score and verbally non-aggressive behaviours subscale score significantly decreased in the intervention group (p < 0.001) although there was no significant evolution in the control group. Direct assessment with the OS produced the same pattern of results, with a significant decrease only in the intervention group. CONCLUSION: The intervention reduced BPSD in severely demented nursing home residents and this effect was still present 3 months after the end of the programme.

[Disorders caused by prolonged exposure to heat]. / Pathologies consécutives a une exposition prolongée a la chaleur.

France has suffered last summer an unprecedented heat wave that led to an exceptional short-term surge of mortality. Cumulative deaths between August 1st to 14th are estimated at 14,800. Epidemiological studies carried out by the Institute de Veille Sanitaire will show the circumstances and risk factors leading to heat-related pathologies. A literature review already shows the principles of prevention, the circumstances of occurrences during similar past heat waves, the risk factors and the principles of treatment. Prolonged exposure to heat can be the initial cause of death, mainly in the elderly. The subject thus dies of an overload of his natural defenses, unable to preserve his thermal homeostasis. This is then a heat shock that reaches the central nervous system. Heat shocks could kill every second patient and leads to severe neurological sequel. During a heat wave, high temperatures can also trigger or worsen other illnesses or be responsible for other so called heat-related syndromes. It is crucially important to identify subjects at risk, situations of risk, and preventive measures, knowing that heat shock leads 25% of patients to develop multi-organ failure, even when appropriately treated.

[Prevention of health risks linked to extreme heat]. / Prévention des risques sanitaires liés aux chaleurs extrêmes.

The prevention of the health risks linked to the excess of heat comprises 5 axes: the sensitisation of fragile persons, families and health personnel to the danger that extreme heat represents; informing and educating about the measures to take before summer and during the scorching heat, identification of persons at risk, protecting, surveilling and alerting them. Two messages predominate: refresh oneself at least 2 hours per day in a cool place (less than 26 degrees C), and drink before being thirsty and beyond the thirst. The efficacity of the measures depend upon the level of general awareness when faced with the health risk that is associated with extreme heat.

The 2008-2012 French Alzheimer plan: a unique opportunity for improving integrated care for dementia.

The 2008-2012 French Alzheimer plan has proposed measures to improve care for dementia patients in a more personalized and graduate approach owing to patients and caregivers needs. A key measure of the plan is the nationwide implementation of the MAIA (French acronym for Maison pour l'Autonomie et l'Intégration des malades d'Alzheimer). The main goal is to implement a process of integration through a network of partners involved in elderly care, assistance, or support. The MAIA model comprises tools and mechanisms necessary to improve the integrated care process; in particular, case management for elderly in complex situations. The purpose of this paper is to describe the main measures from the national plan that aim to improve care for dementia patients with an emphasis on the MAIA measure. We summarize initial results of case management activity in one MAIA in the South West of France and we present two vignettes of cases benefiting from case management in order to demonstrate the nature of intervention. The French Alzheimer plan has promoted several non-pharmacological strategies for dementia patients. Implementation of both integrated care and case management represent a challenging perspective for the elderly and health professionals.