[DemStepCare: Risk-stratified support for primary care-based dementia care - evaluation from general practitioner's view]. / DemStepCare: Risikostratifizierte Unterstützung der ambulanten Demenzversorgung ­ Bewertung aus hausärztlicher Perspektive.

OBJECTIVE: The innovation fund project DemStepCare aimed to optimize multi-professional care through case management, risk stratification, and crisis outpatient clinic. Here, the evaluation results from the perspective of the general practitioners are presented. METHODS: A quantitative survey was carried out at three time points regarding acceptance, benefit assessment and sensitivity to dementia of the general practitioners. In addition, qualitative interviews were conducted. RESULTS: Satisfaction with the overall project was high. Added value and relief factors were perceived and more effective and stable dementia care was achieved through collaboration with case management. Physicians reported increased subjective competence in diagnostics and disease management. CONCLUSIONS: The results confirm the benefit and effectiveness of DemStepCare from general practitioner's perspective.

Psychobiological Evaluation of Day Clinic Treatment for People Living With Dementia - Feasibility and Pilot Analyses.

Background: Hospitalization is often stressful and burdensome for people living with dementia (PwD) and their informal caregivers (ICs). Day clinic treatment may provide a suitable alternative, but is often precluded by a diagnosis of dementia. Furthermore, it is often caregiver-based ratings that measure treatment success as the validity of self-reports in PwD is critically discussed. We therefore set out to examine the feasibility of psychobiological stress measures in PwD and ICs and to evaluate treatment trajectories considering both the day clinic context and the daily life of the dyads. Method: A total of 40 dyads of PwD (mean age: 78.15 ± 6.80) and their ICs (mean age: 63.85 ± 13.09) completed paper-and-pencil questionnaires (covering stress, depressive symptoms, and caregiver burden among others) in addition to the measurement of hair cortisol concentrations (HCC) at admission, discharge, and follow-up 6 months after day clinic treatment. As part of an ambulatory assessment, for 2 days at the beginning and 2 days at the end of the day clinic treatment, PwD and ICs collected six saliva samples per day for the analysis of salivary cortisol (sCort) and alpha-amylase (sAA). Results: Paper-and-pencil questionnaires and HCC assessments were more feasible than the ambulatory assessment. We found discrepancies between subjective and physiological markers of stress in PwD. Whereas HCC decreased over time, self-reported stress increased. Child-parent dyads reported decreases in neuropsychiatric symptoms, associated burden, and self-reported stress from admission to follow-up. In daily life, both PwD and ICs showed characteristic diurnal profiles of sAA and sCort, however, we found no differences in summary indicators of salivary stress markers over time. Discussion: The psychobiological evaluation was feasible and added informative value, underlining the potential of physiological stress markers to complement self-reports on stress in PwD and to objectively evaluate treatment trajectories. In this sample, HCC was more feasible and acceptable as biological marker of stress compared to saliva samples. Concerning treatment trajectories, differential effects on the dyads were found, with child-parent dyads benefiting more from day clinic treatment compared to spousal dyads.

Psychobiological Monitoring of a Home-Based Dyadic Intervention for People Living with Dementia and Their Caregivers: Added Value to Evaluate Treatment Success and Understand Underlying Mechanisms.

BACKGROUND: Research concerning people living with dementia (PwD) and their informal caregivers (ICs) has recently begun to focus on dyadic aspects of psychosocial interventions. OBJECTIVE: We adapted a dyadic psychosocial intervention and examined its effects on psychobiological stress in daily life. METHODS: Twenty-four PwD-caregiver dyads were visited seven times at home by specialized nursing staff. Momentary subjective stress, salivary cortisol (sCort), and salivary alpha-amylase (sAA) were measured in PwD and ICs before and after each home visit as well as six times per day at two days each at the beginning and end of the intervention as part of an ambulatory assessment. Hair cortisol concentrations (HCC) were measured twice. RESULTS: After each home visit session, ICs reported lower subjective stress. sCort was lower in both ICs and PwD, whereas sAA did not change. In daily life, area under the curve (AUCg) concerning sCort secretion indicated that PwD had lower sCort daily output at the end of the intervention, and AUCg concerning subjective stress indicated that both PwD and ICs reported lower subjective stress than at the beginning of the intervention. AUCg concerning sAA did not change over time in either group. HCC did not vary over time but increased with disease severity. CONCLUSION: The psychosocial intervention reduced psychobiological stress but affected psychobiological stress measures differently in PwD and ICs. In particular, the discrepancy between subjective and physiological markers of stress in PwD emphasizes the added value to evaluate treatment success and understand underlying mechanisms as a complement to self-reports.

Lifetime musical training and cognitive performance in a memory clinic population: A cross-sectional study.

BACKGROUND: Music training has been found to be beneficial for young and healthy participants but the associations between musical training and the cognitive functioning of elderly participants have not been reported consistently. We examined whether lifetime musical training is associated with neuropsychological performance in a memory clinic population of older patients. METHODS: A total of 478 patients (54.2% female, mean age 73.70 ± 6.22, mean Mini Mental State Examination score 25 ± 3) were included in the cross-sectional analyses. All patients were referred to the memory clinic due to cognitive impairments. During the course of diagnosis, all patients underwent neuropsychological tests using the CERAD neuropsychological assessment battery. Patients provided information on whether they ever learned to play an instrument for at least five years in their life. RESULTS: Neuropsychological test results differed based on musical training (p = .042). Overall, there were no differences in any domains of cognitive functioning, other than that patients with musical training performed worse on word list memory (p = .008). However, this relationship varied based on the extent of cognitive impairments. Patients who were cognitively unimpaired (Mini Mental State Examination score 27-30) and had musical training showed better word list learning, whereas patients with cognitive impairments (Mini Mental State Examination score < 27) and musical training performed worse in word list learning (p = .042) and word list recall (p = .045). DISCUSSION: Overall, there was little evidence of associations between specific neuropsychological test results and musical training. Only in cognitively unimpaired patients was there evidence that musical training had beneficial associations. In patients with cognitive impairment, there were suggestions of negative associations with verbal memory. Future research should longitudinally investigate the beneficial effects of musical training in people with and without cognitive impairments.

Introduction and Psychometric Validation of the Resilience and Strain Questionnaire (ResQ-Care)- A Scale on the Ratio of Informal Caregivers' Resilience and Stress Factors.

Background: Informal caregivers are a particularly vulnerable population at risk for adverse health outcomes. Likewise, there are many scales available assessing individual caregiver burden and stress. Recently, resilience in caregivers gained increasing interest and scales started to assess resilience factors as well. Drawing on a homeostatic model, we developed a scale assessing both caregivers' stress and resilience factors. We propose four scales, two covering stress and two covering resilience factors, in addition to a sociodemographic basic scale. Based on the stress:resilience ratio, the individual risk of adverse health outcomes and suggestions for interventions can be derived. Methods: A total of 291 informal caregivers filled in the ResQ-Care as part of a survey study conducted during the second wave of the COVID-19 pandemic in Germany. Exploratory factor analysis was performed. Validity analyses were examined by correlations with the Brief Resilience Scale (BRS), the Perceived Stress Scale (PSS-4) and the Geriatric Depression Scale (GDS-15). Results: The data fitted our proposed four-factor solution well, explaining 43.3% of the variance. Reliability of each scale was at least acceptable with Cronbach's α ≥0.67 and MacDonald's ω ≥0.68 for all scales. The two strain scales weighed more than the resilience scales and explained 65.6% of the variance. Convergent and discriminant validity was confirmed for the BRS and PSS-4, whereas the GDS-15 correlation pattern was counterintuitive. Conclusion: The factor structure of the ResQ-Care scale was confirmed, with good indications of reliability and validity. Inconsistent correlations of the scales with the GDS-15 might be due to a reduced validity of GDS-15 assessment during the COVID-19 lockdown.

Primary dementia care based on the individual needs of the patient: study protocol of the cluster randomized controlled trial, DemStepCare.

BACKGROUND: Most people with dementia (PwD) are cared for at home, with general practitioners (GPs) playing a key part in the treatment. However, primary dementia care suffers from a number of shortcomings: Often, diagnoses are made too late and therapies by GPs do not follow the guidelines. In cases of acute crises, PwD are too often admitted to hospital with adverse effects on the further course of the disease. The aim of this study is to implement and evaluate a new GP-based, complex dementia care model, DemStepCare. DemStepCare aims to ensure demand-oriented, stepped care for PwD and their caregivers. METHODS/DESIGN: In a cluster randomized controlled trial, the care of PwD receiving a complex intervention, where the GP is supported by a multi-professional team, is compared to (slightly expanded) usual care. GPs are clustered by GP practice, with 120 GP practices participating in total. GP practices are randomized to an intervention or a control group. 800 PwD are to be included per group. Recruitment takes place in Rhineland-Palatinate, Germany. In addition, a second control group with at least 800 PwD will be formed using aggregated routine data from German health insurance companies. The intervention comprises the training of GPs, case management including repeated risk assessment of the patients' care situation, the demand-oriented service of an outpatient clinic, an electronic case record, external medication analyses and a link to regional support services. The primary aims of the intervention are to positively influence the quality of life for PwD, to reduce the caregivers' burden, and to reduce the days spent in hospital. Secondary endpoints address medication adequacy and GPs' attitudes and sensitivity towards dementia, among others. DISCUSSION: The GP-based dementia care model DemStepCare is intended to combine a number of promising interventions to provide a complex, stepped intervention that follows the individual needs of PwD and their caregivers. Its effectiveness and feasibility will be assessed in a formative and a summative evaluation. TRIAL REGISTRATION: German Register of Clinical Trials (Deutsches Register Klinischer Studien, DRKS), DRKS00023560 . Registered 13 November 2020 - Retrospectively registered. HTML&TRIAL_ID=DRKS00023560.

Psychobiological mechanisms underlying the health-beneficial effects of music in people living with dementia: A systematic review of the literature.

BACKGROUND: Music has been used as agent in medicine for decades. The applications of music in health span from music therapy to music listening interventions to mere music listening. Music may reduce stress and improve health in people living with dementia (PwD), but the exact underpinnings of these effects are unclear. It is proposed that beneficial effects of music are mediated by a reduction in psychobiological stress. Therefore, the present review aims to shed light on the potential psychobiological mechanisms underlying the health-beneficial effects of music in PwD. METHODS: We searched for studies investigating health-beneficial effects of music in PwD by means of psychobiological stress measures using the PubMed, PsycINFO and Web of Science databases and by hand-searching. RESULTS: The inclusion criteria were met by 12 studies. Seven of the included studies investigated effects of music therapy on the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal (HPA) axis or the immune system in patients with mild to moderate dementia. Results showed decreased ANS activity as measured by heart rate variability but no effect on alpha-amylase. Effects on blood pressure were mixed. Concerning the secretion of cortisol, one study found decreased HPA axis activity whereas two studies found no significant effects. No effects were found on salivary immunoglobin A. Three studies investigated the effects of music listening interventions in patients with severe dementia by means of predominantly ANS parameters with evidence indicating increased parasympathetic activation after music listening. Two studies investigated the effects of mere music listening on skin conductance using experimental designs. One study found increases in arousal due to music listening, whereas the other study found no effect. DISCUSSION AND CONCLUSION: These very preliminary results indicate effects of music on central stress pathways in PwD, but also highlight the need for further research focussing on a comprehensive assessment of autonomic, endocrine and immunological parameters in response to music. Furthermore, future studies should directly compare music therapy to music listening interventions and mere music listening in samples of PwD of varying disease severity and varying care settings.

Dyadic Wind of Change: New Approaches to Improve Biopsychological Stress Regulation in Patients with Dementia and Their Spousal Caregivers.

Patients with dementia (PWD) and their caregivers experience long-term stress, leading to accelerated disease progression and to stress-related morbidity. Previous research focused on intrapersonal biopsychological stress responses. Quite recently, dyadic interrelations between caregivers and PWD and their effects on stress and caregiver burden have received more attention, giving rise to dyadic intervention studies. However, while it is of importance to consider both the patient and the caregiver from a dyadic point of view, evaluation of these dyadic interventions considering underlying mechanisms is still lacking. We therefore extend the current literature on dyadic processes between PWD and caregivers by transferring the knowledge about underlying stress-modulating dyadic processes in healthy couples to the dementia patient-caregiver constellation. By targeting dyadic stress co-regulation between PWD and caregivers, we expect significant therapeutic effectiveness. The aims of this article are two-fold: 1) We aim to provide a rationale for incremental benefits of considering dyadic processes among caregivers and PWD by means of elucidating underlying mechanisms and 2) we aim to emphasize the need to evaluate these underlying mechanisms by means of objective physiological stress markers in both PWD and caregivers. Knowledge on these underlying mechanisms will ultimately help developing dyadic interventions tailored to the needs of both PWD and their caregivers.

The Aim Justifies the Means-Differences Among Musical and Nonmusical Means of Relaxation or Activation Induction in Daily Life.

Music is an effective means of stress-reduction. However, to date there has been no systematic comparison between musical and language-based means of stress reduction in an ambulatory setting. Furthermore, although the aim for listening to music appears to play a role in its effect, this has not yet been investigated thoroughly. We compared musical means, language-based means like guided relaxation or self-enhancement exercises, and a combination of both with respect to their potential to reduce perceived stress. Furthermore, we investigated whether the aim one wants to achieve by listening to these means had an impact on their effect. We tested 64 participants (age: M = 40.09 years; 18 female) for 3-10 days during their everyday life using an app containing three means: musical means, language-based means, and a combination of both. For the music and the combination conditions participants were asked to select an aim: relaxation or activation. We measured perceived stress, relaxation, activation, and electrical skin resistance (ESR) as a marker of sympathetic nervous system (SNS) activity before and after using the app. Participants were instructed to use the app as often as desired. Overall, perceived stress was reduced after using the app, while perceived relaxation and activation were increased. There were no differences between the three means regarding their effect on perceived stress and relaxation, but music led to a greater increase in ESR and perceived activation compared to the other means. There was a decrease in ESR only for music. Moreover, perceived stress was reduced and perceived relaxation was increased to greater extent if the aim "relaxation" had been selected. Perceived activation, however, showed a larger increase if the aim had been "activation," which was even more marked in the case of music listening. Our results indicate that all three means reduced perceived stress and promoted feelings of relaxation and activation. For enhancing feelings of activation music seems to be more effective than the other means, which was reflected in increased SNS activity as well. Furthermore, the choice of an aim plays an important role for the reduction of stress, and promotion of relaxation and activation.