Evidence-Based Non-Pharmacological Therapies for

Early-Stage Dementia: Implications for Clinical Practice

Presented by:Sandy C. Burgener, PhD, GNP – BC, FAAN

Associate ProfessorUniversity of Illinois College of Nursing

Adjunct Associate Professor of NeurologySouthern Illinois University Center for

Alzheimer Disease and Related DisordersPartial funding from: National Alzheimer’s Association, Chicago, Illinois

Support for Non-Pharmacological Therapies

for Early-Stage DementiaSelf-identified need of persons with early-

stage dementia (Results of AA town hall meetings)

Gap in community-based services: Diagnosis → Adult day care services

Limitations of current drug therapiesGrowing body of research supporting positive

effects of non-pharmacological therapies

Criteria for Grading the Strength of the Research

A1 = Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action

A2 = Evidence from one or more randomized controlled trials with consistent results

B1 = Evidence from high quality evidence-based practice guidelines

B2 = Evidence from one or more quasi-experimental studies with consistent results

C1 = Evidence from observational studies with consistent results (e.g. correlational, descriptive studies)

C2 = Inconsistent evidence from observational studies or controlled trials

D = Evidence from expert opinion, multiple case reports, or national consensus reports

Theoretical Frameworks Guiding Non-Pharmacological Interventions

Enablement Model

Progressively Lowered Stress Threshold

Need-Driven Dementia-Compromised Behavior Model

Plasticity Theory and the Effects of Enriched Environments on Neuronal Regeneration

Plasticity TheoryEarly animal studies suggest brain, after

injury, is capable of responding to external stimuli, called ‘enriched environments.’ (EE) (Black, Sirevaag, Greenough, 1987)

EE effects on brain structure:– Increased synapses per neuron.– Increased neuronal density.– New neuronal sprouting: increased numbers of

neurons.– Slowing of cell death.

Plasticity Theory (Cont’d)Behavioral and cognitive effects of EE

include:– Increased spatial learning.– Improve overall learning.– Regaining of motor skills.

Inconsistent findings in cell proliferation between groups (EE, exercise only, control) (Briones, et al., 2005)

Enriched Environment Components

Based on animal and human (TBI) studies:

Structured exercise (beyond baseline)Multiple environmental stimuli:

• Music• Cognitive tasks• Opportunity to explore environment

Social interactionsVaried, intense stimuli

• Novel stimuli

Exercise Interventions: n=11 36% = A 55% = B 9% = C Most studies were randomized,

controlled trials. Outcomes include:

– Improved cognition.– Improved physical and functional

ability.– Less depression. – Fewer behavioral symptoms in

exercisers compared to non-exercisers.

Tested exercise forms include:– Home-based aerobic/endurance

activities.– Strength training.– Balance and flexibility training. – Tai Chi (2 studies).

Effects of Aerobic Exercise on Brain

Delay or reverse cerebral structural & functional changes*

Delay beta-amyloid accumulation*Improves memory*Increases brain-derived neurotrophic

factor (BDNF): a neurotrophin associated with learning, cell health

*Studies with transgenic mice

Effects of Aerobic Exercise on Brain

Protects against hyperinsulinemia and insulin resistanceIncreased dopamine levels in the brainIncreases cerebral vasculature and blood flow

Exercise Studies: Conclusions Importantly, the exercise

type with greatest benefits (animal studies):• Acrobatic exercises• Requires motor learning

Recommended exercise forms:• Aerobic exercises• Exercises that require motor

learning, ie, Tai Chi

Cognitive Training & Enhancement Programs: n=41

47% = A 16% = B 30% = C 7% = D Outcomes include:

• Improved memory and mental status.• Errorless learning achievement.• Improved executive functioning.• Improved functioning in activities of daily living.• Decreased depression.

Importantly, in longitudinal studies where a control group was used, persons with AD who received a cognitive enhancement intervention maintained higher MMSE scores compared with the control group for up to two years following the intervention.

Effects of Cognitive Training on the Brain

Increased dendritic sprouting Enhanced CNS plasticityImproved memory storage and retrievalImproved executive functioningDecreased depressionEffects of cognitive training similar to

effects of dementia-specific medications on cognitive functioning

Cognitive Training DefinitionsCognitive training: Guided practice on a set

of standard tasks designed to reflect particular cognitive functions, such as memory, attention, or problem-solving (executive function).

Cognitive rehabilitation: More individualized approach to helping persons with cognitive impairments with more of an emphasis on improving everyday functioning.

Reference: Clare, et al., 2009

Limitations of Cognitive Training Research

Lack of consistency regarding content of intervention

Training effects do not generalize to other functions; positive effects are found only for target cognitive function.

Wide variation in:– Length of intervention– Delivery format (home, group, individual)– Involvement of family caregiver

Early-Stage Support Groups: n=13 12% = B 55% = C 33% = D• Most include an educational and

social support component: 8 to 10 weeks in length

• Studies lack a quantitative design and systematic outcome evaluation

• Small sample sizes, typically 8 to 20 participants

• Age-matched control groups lacking

• Participation is ‘terminated’ at the end of the formal sessions, with the exception of the ‘Alzheimer’s Café’ in the Netherlands.

Exemplar Programs: n=14 36% = A 29% = B 36% = C Multimodal interventions demonstrate great promise due to

power of the intervention and the effects on a variety of outcomes.

Outcomes include:– Improved cognition and physical abilities.– Lower depressive symptoms. – Heightened self-esteem.– Enhanced communication ability.

Despite small sample sizes, technology-based programs offer strong promise for the future as an exemplary method to:– Minimize the need for professional support services.– Be utilized by family caregivers.– Be widely disseminated.

Components of Multi-Modal Interventions

Two or more of the following treatments:

Exercise (aerobic, endurance, Taiji, strength training, balance, flexibility training)

Caregiver training in behavior managementCognitive exercisesCognitive-behavioral therapiesReality orientation

Components of Multi-Modal Interventions (Cont’d)

Nutritional intervention (high-protein supplement)

Conversational stimulationVolunteer service or meaningful

community activityCollege courseRecreational and social therapiesFamily involvement and therapies

Health Promotion Interventions: n=3237% = A25% = B31% = C7% = DSupport for sleep hygiene interventions:

• For sleep enhancement in the home-setting, despite limited number of studies

Few definitive dietary recommendations can be made, other than inclusion of naturally occurring antioxidants. Translational research studies need to be conducted.

Health Promotion Interventions (Cont’d)

Falls in persons with early-stage dementia are associated with:– Increased cognitive impairment.– Environmental hazards.– Changes in balance and equilibrium.– Distractions while walking or performing a task. Few studies have been conducted testing interventions for

fall prevention.

College course for health promotion (one study): Outcomes include:

• Lower depression.• Lower anxiety.• Improved self-esteem.

‘Other’ InterventionsVolunteer Programs: Outcomes include:

– Increased language and memory skills– Positive caregiver perceptions of volunteer work for

persons with dementia Writing interventions: Benefits of writing

interventions are sparse and descriptive in nature.

Technology-based interventions:– Hampered by the small sample sizes – Limited studies to date– Descriptive in nature, with only one study utilizing

a comparison group

Early-Stage Dementia:Non-Pharmacological Treatment

Protocol Multi-modal intervention programs Physical exercise, preferably aerobic or mindful

exercises: If aerobic exercises cannot be tolerated, then exercises that

are less-strenuous yet promote strength, balance, coordination, and require motor learning, such as Tai Chi

Cognitive training programs: Preferably, therapies that use cognitive training and rehabilitation as the focus of the training

Comprehensive college courses and recreational therapies, including such activities as art, writing, social engagement, individualized hobbies

Support group participation (continuous, not time-limited)

Sleep hygiene programs, such as NITE-AD

Early-Stage Dementia:Non-Pharmacological Treatment Protocol Dietary modifications to include foods that

are rich in antioxidants: Blueberries, spinach, and strawberries

Driving evaluations, at least every 6 months: Including an on-road test with an experienced

driving specialist Individualized instruction and training in

activities to promote independence: Cell phone usage, computer e-mail programs, etc.

Electronic reminder and monitoring support programs, if not cost prohibitive

Model of Community-Based Non-Pharmacological Treatment

ProgramCenter for Positive Aging:

Buettner & Fitzsimmons

Minds in Motion and Lunch & Learn: Burgener

Brookdale-funded programs: Early-Memory Loss Programs

Recruitment and Retention in Early-Stage Programs

Brookdale-funded programs recruitment: Establish positive relationships with

collaborative, community agencies:– Adult day care centers– Centers for aging– Geriatric-focused medical practices

Disseminate information in geriatric-focused publications

Positive reputation: Word of mouth

Recruitment and Retention in Early-Stage Programs

High retention rates:Positive outcomes: Experience benefits

of program participationMaintaining appropriate participant levelCollaboration with community groups to

transition more impaired participantsEnjoyable, varied activitiesCompetent, appropriate program leaders

Positive Outcomes of Community-Based Programs

Improved or sustained cognitive functioning compared to controlsImproved (less) depressionHigher QoL scoresImproved self-esteem compared to controlsImproved physical functioning (balance and lower leg strength)Lower stressLow attrition ratesOverall improved social functioning

ConclusionsEvidence exists for the effectiveness of a wide

variety of non-pharmacological therapies.Non-pharmacological therapies are rarely

recommended following dementia diagnosis.Availability of non-pharmacological therapies

is limited, presenting barriers to participation and possible positive benefits.

Dual therapies may offer significant benefits over medication-therapy alone, but they are not widely tested.

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