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

1. Evidence-Based Non-Pharmacological Therapies for Early-Stage Dementia: Implications for Clinical Practice Presented by: Sandy C. Burgener, PhD, GNP – BC, FAAN Associate Professor University of Illinois College of Nursing Adjunct Associate Professor of Neurology Southern Illinois University Center for Alzheimer Disease and Related Disorders Partial funding from: National Alzheimer’s Association, Chicago, Illinois

2. Support for Non-Pharmacological Therapies for Early-Stage Dementia • Self-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 therapies • Growing body of research supporting positive effects of non-pharmacological therapies

3. 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

4. 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

5. Plasticity Theory • Early 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.

6. 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)

7. 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 interactions • Varied, intense stimuli • Novel stimuli

8. 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).

9. 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

10. Effects of Aerobic Exercise on Brain • Protects against hyperinsulinemia and insulin resistance • Increased dopamine levels in the brain • Increases cerebral vasculature and blood flow

11. 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

12. 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.

13. Effects of Cognitive Training on the Brain • Increased dendritic sprouting • Enhanced CNS plasticity • Improved memory storage and retrieval • Improved executive functioning • Decreased depression • Effects of cognitive training similar to effects of dementia-specific medications on cognitive functioning

14. Cognitive Training Definitions • Cognitive 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

15. 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

16. 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.

17. 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.

18. 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 management • Cognitive exercises • Cognitive-behavioral therapies • Reality orientation

19. Components of Multi-Modal Interventions (Cont’d) • Nutritional intervention (high-protein supplement) • Conversational stimulation • Volunteer service or meaningful community activity • College course • Recreational and social therapies • Family involvement and therapies

20. Health Promotion Interventions: n=32 • 37% = A • 25% = B • 31% = C • 7% = D • Support 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.

21. 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.

22. ‘Other’ Interventions • Volunteer 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

23. 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

24. 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

25. Model of Community-Based Non-Pharmacological Treatment Program • Center for Positive Aging: Buettner & Fitzsimmons • Minds in Motion and Lunch & Learn: Burgener • Brookdale-funded programs: Early-Memory Loss Programs

26. 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

27. Recruitment and Retention in Early-Stage Programs High retention rates: • Positive outcomes: Experience benefits of program participation • Maintaining appropriate participant level • Collaboration with community groups to transition more impaired participants • Enjoyable, varied activities • Competent, appropriate program leaders

28. Positive Outcomes of Community-Based Programs • Improved or sustained cognitive functioning compared to controls • Improved (less) depression • Higher QoL scores • Improved self-esteem compared to controls • Improved physical functioning (balance and lower leg strength) • Lower stress • Low attrition rates • Overall improved social functioning

29. Conclusions • Evidence 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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