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'''Cognitive therapies for dementia''' are starting to gain some momemtum. Improved clinical assessment in early stages of Alzheimer's desease and other forms of dementia, increased cognitive stimulation of the elderly, and the prescription of drugs to slow cognitive decline have resulted in increased detection in the early stages<ref>http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=2816&nbr=2042</ref><ref>http://findarticles.com/p/articles/mi_m0857/is_11_12/ai_n17215917</ref><ref>http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec4.html</ref>. Although the opinions of the medical community are still apprehensive to support cognitive therapies in dementia patients, recent international studies have started to create optimism. <ref>{cite journal PMID: 16228161}</ref>
==Cognitive therapies for dementia==

Memory rehabilitation for dementia patients is starting to gain some momemtum. Improved clinical assessment in early stages of Alzheimer's desease and other forms of dementia, increased cognitive stimulation of the elderly, and the prescription of drugs to slow cognitive decline have resulted in increased detection in the early stages<ref>http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=2816&nbr=2042</ref><ref>http://findarticles.com/p/articles/mi_m0857/is_11_12/ai_n17215917</ref><ref>http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec4.html</ref>. Although the opinions of the medical community are still apprehensive to support cognitive therapies in dementia patients, recent international studies have started to create optimism. <ref>{cite journal PMID: 16228161}</ref>
==Classification and efficacy of the different therapies==
Interventions are used as an adjunct to pharmaceutical treatment and can be classified within behavior, emotion, cognition or stimulation oriented approaches. Research on efficacy is reduced.<ref name="pracGuideAPA">{{cite web
| url=http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007
| format=PDF
| title =Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias
| publisher =[[American Psychiatric Association]]
| date=October 2007
| accessdate=2007-12-28
| doi=10.1176/appi.books.9780890423967.152139
}}</ref>

===Behavioral interventions===
[[Behavior modification|Behavioral interventions]] attempt to identify and reduce the antecedents and consequences of problem behaviors. This approach has not shown success in the overall functioning of patients,<ref name="pmid16323385">{{cite journal
|author=Bottino CM, Carvalho IA, Alvarez AM, ''et al''
|title=Cognitive rehabilitation combined with drug treatment in Alzheimer's disease patients: a pilot study
|journal=Clin Rehabil
|volume=19
|issue=8
|pages=861–9
|year=2005
|pmid=16323385
|doi=
}}</ref>
but can help to reduce some specific problem behaviors, such as [[Urinary incontinence|incontinence]].<ref name="pmid11342679">{{cite journal
|author=Doody RS, Stevens JC, Beck C, ''et al''
|title=Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology
|journal=Neurology
|volume=56
|issue=9
|pages=1154–66
|year=2001
|pmid=11342679
|doi=
}}</ref> There is still a lack of high quality data on the effectiveness of these techniques in other behavior problems such as wandering.<ref name="pmid17253573">{{cite journal
|author=Hermans DG, Htay UH, McShane R
|title=Non-pharmacological interventions for wandering of people with dementia in the domestic setting
|journal=Cochrane Database Syst Rev
|volume=
|issue=1
|pages=CD005994
|year=2007
|pmid=17253573
|doi=10.1002/14651858.CD005994.pub2
}}</ref><ref name="pmid17096455">{{cite journal
|author=Robinson L, Hutchings D, Dickinson HO, ''et al''
|title=Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review
|journal=Int J Geriatr Psychiatry
|volume=22
|issue=1
|pages=9–22
|year=2007
|pmid=17096455
|doi=10.1002/gps.1643
}}</ref>

===Emotion-oriented interventions===
Emotion-oriented interventions include [[reminiscence therapy]], [[validation therapy]], supportive [[psychotherapy]], sensory integration or [[snoezelen]], and [[simulated presence therapy]]. Supportive psychotherapy has received little or no formal scientific study, but some clinicians find it useful in helping mildly impaired patients adjust to their illness.<ref name="pracGuideAPA">{{{{cite web
| url=http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007
| format=PDF
| title =Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias
| publisher =[[American Psychiatric Association]]
| date=October 2007
| accessdate=2007-12-28
| doi=10.1176/appi.books.9780890423967.152139
}}</ref>
Reminiscence therapy (RT) involves the discussion of past experiences individually or in group, many times with the aid of photographs, household items, music and sound recordings, or other familiar items from the past. Although there are few quality studies on the effectiveness of RT it may be beneficial for [[cognition]] and [[Mood (psychology)|mood]].<ref name="pmid15846613">{{cite journal
|author=Woods B, Spector A, Jones C, Orrell M, Davies S
|title=Reminiscence therapy for dementia
|journal=Cochrane Database Syst Rev
|volume=
|issue=2
|pages=CD001120
|year=2005
|pmid=15846613
|doi=10.1002/14651858.CD001120.pub2
}}</ref>
Simulated presence therapy (SPT) is based on [[Attachment theory|attachment theories]] and is normally carried out playing a recording with voices of the closests relatives of the patient. There is preliminary evidence indicating that SPT may reduce [[anxiety]] and [[Challenging behaviour|challenging behaviors]].<ref name="pmid11827626">{{cite journal
|author=Peak JS, Cheston RI
|title=Using simulated presence therapy with people with dementia
|journal=Aging Ment Health
|volume=6
|issue=1
|pages=77-81
|year=2002
|pmid=11827626
|doi=10.1080/13607860120101095
}}</ref><ref name="pmid10203120">{{cite journal
|author=Camberg L, Woods P, Ooi WL, ''et al''
|title=Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease
|journal=J Am Geriatr Soc
|volume=47
|issue=4
|pages=446-52
|year=1999
|pmid=10203120
|doi=
}}</ref>
Finally, validation therapy is based on acceptance of the reality and personal truth of another's experience, while sensory integration is based on exercises aimed to stimulate [[sense]]s. There is little evidence to support the usefulness of these therapies.<ref name="pmid12917907">{{cite journal
|author=Neal M, Briggs M
|title=Validation therapy for dementia
|journal=Cochrane Database Syst Rev
|volume=
|issue=3
|pages=CD001394
|year=2003
|pmid=12917907
|doi=10.1002/14651858.CD001394
}}</ref><ref name="pmid12519587">{{cite journal
|author=Chung JC, Lai CK, Chung PM, French HP
|title=Snoezelen for dementia
|journal=Cochrane Database Syst Rev
|volume=
|issue=4
|pages=CD003152
|year=2002
|pmid=12519587
|doi=
}}</ref>

===Cognition-oriented treatments===
The aim of cognition-oriented treatments, which include reality orientation and [[Rehabilitation (neuropsychology)|cognitive retraining]] is the restoration of [[cognitive deficit]]s. Reality orientation consists in the presentation of information about time, place or person in order to ease the understanding of the person about its surroundings and his place in them. On the other hand cognitive retraining tries to improve impaired capacities by exercitation of mental abilities. Both have shown some efficacy improving cognitive capacities,<ref name="pmid17636652">{{cite journal
|author=Spector A, Orrell M, Davies S, Woods B
|title=WITHDRAWN: Reality orientation for dementia
|journal=Cochrane Database Syst Rev
|volume=
|issue=3
|pages=CD001119
|year=2000
|pmid=17636652
|doi=10.1002/14651858.CD001119.pub2
}}</ref><ref name="pmid12948999">{{cite journal
|author=Spector A, Thorgrimsen L, Woods B, ''et al''
|title=Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial
|journal=Br J Psychiatry
|volume=183
|issue=
|pages=248-54
|year=2003
|pmid=12948999
|doi=
}}</ref> although in some works these effects were transient and negative effects, such as frustation, have also been reported.<ref name="pracGuideAPA">{{{{cite web
| url=http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007
| format=PDF
| title =Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias
| publisher =[[American Psychiatric Association]]
| date=October 2007
| accessdate=2007-12-28
| doi=10.1176/appi.books.9780890423967.152139
}}</ref> Some of the programms inside this approach are fully or partially computerized, such as the [[Cognitive Retention Therapy]] method.<ref>http://www.elderwise.ca/Early%20Intervention%20AD.pdf</ref><ref>Section C2 [http://www.alzheimers.ca/english/newsevents/conference-programdetails.htm Alzheimer's Society of Canada]</ref>

===Stimulation-oriented treatments===
Stimulation-oriented treatments include [[Art therapy|art]], [[Music therapy| music]] and [[Animal-assisted therapy|pet]] therapies, [[Physical therapy|exercise]], and any other kind of [[Recreational therapy|recreational activities]] for patients. Stimulation has modest support for improving behavior, mood, and, to a lesser extent, function. Nevertheless, as important as these effects are, the main support for the use of stimulation therapies is the improvement in the patient daily life routine they suppose.<ref name="pracGuideAPA">{{{{cite web
| url=http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007
| format=PDF
| title =Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias
| publisher =[[American Psychiatric Association]]
| date=October 2007
| accessdate=2007-12-28
| doi=10.1176/appi.books.9780890423967.152139
}}</ref>


==Summary of article by the American Journal of Psychiatry<ref>[http://ajp.psychiatryonline.org/cgi/reprint/162/11/1996/ American Journal of Psychiatry]</ref> ==
==Summary of article by the American Journal of Psychiatry<ref>[http://ajp.psychiatryonline.org/cgi/reprint/162/11/1996/ American Journal of Psychiatry]</ref> ==
Line 39: Line 199:
::''"Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms. Lack of evidence regarding other therapies is not evidence of lack of efficacy. Conclusions are limited because of the paucity of high-quality research (only nine level-1 studies were identified). More high-quality investigation is needed."''
::''"Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms. Lack of evidence regarding other therapies is not evidence of lack of efficacy. Conclusions are limited because of the paucity of high-quality research (only nine level-1 studies were identified). More high-quality investigation is needed."''


== Promising therapies ==
{{Unreferencedsection|date=February 2008}}

There are things that can be done to help improve the symptoms of [[Alzheimer's disease]], [[Lewy body]] and other [[dementia]]. Some of the promising therapies are [[Social interaction]], [[Reminiscence therapy|Reminiscence Therapy]], Cognitive Stimulation Therapy, [[Music Therapy]], [[Snoezelen]] and Environmental manipulation.

===Social Interaction===
'''Social Interaction''' refers to "enforced social interaction" with nurses and care givers. Some reports show decreased neuropsychiatric symptoms in one-third of patients who had enforced social interaction with nurses for three hours a day.

===Reminiscent Therapy===
'''Reminiscence Therapy''' is a somewhat low cost therapy to help patients reflect on their lives. By using old newspapers, household items, photographs, music and other materials from certain time periods, the goal is to stimulate the patient's memory and have them reflect on their life history. Often offered in group settings, reminiscence therapy can be used in nursing homes, retirement homes and adult day cares to generate discussion between like-minded people about experiences they may share. Reflecting on the war for instance is a common focus point, bringing back strong emotional memories. When combined with reality orientation reminiscence therapy may help improve behavior in dementia participants.
===Cognitive Stimulation Therapy===
'''Cognitive Stimulation Therapy''' uses factual information processing to stimulate the brain by making it remember, think, and provide a result. It is an evidence-based system. Results of studies conducted on CST show it to improve neuropsychiatric symptoms in persons with dementia both immediately and for months afterwards. It has been also shown to improve mood, and possibly delay institutionalization.

===Music Therapy===
'''Music Therapy''' is when a trained professional uses music to improve skills such as motor skills, social skills, cognitive and other abilities. Music therapy has shown to be useful in calming dementia patients' behavior during sessions.

===Snoezelen===
'''Snoezelen''' is a type of multisensory stimulation in a controlled environment or "snoezelen room". The goal is to provide a calming setting controlling lights, sounds, scents etc. Originally developed in the Netherlands in the 70s, it is used in institutions around the world. Snoezelen rooms are very costly to create. Snoezelen has shown to reduce agitation and improve behavior of patients with dementia during sessions.

===Environmental manipulation===
'''Environmental manipulation''' refers to creating visually complex environments using things like mirrors, placing horizontal grid patterns and murals over doors, signposting, and other ways to control the visual environment. Not really an Alzheimer's Treatment but does show potential when obscuring the exits with murals and other distractions, reducing the exiting or wandering behaviors of patients with dementia.

== Cognitive Retention Therapy==
'''[[Cognitive Retention Therapy]]''' also referred to as CRT or the "Ashby Method" is based on the research of Dr. [[Mira Ashby]], CRT is adapted from her programs for brain injury rehabilitation. Using '''Cognitive Stimulation Therapy''', a process called [[errorless learning]], [[Stroop effect|Stroop exercises]] and other forms of sensory stimulation all centered around and designed specifically for the individual patient. Although still in preliminary stages of clinical trials the Ashby Method has received wide acceptance in the dementia care community as a plausible treatment for [[Alzheimer's disease]] and other [[dementia]].<ref>http://www.elderwise.ca/Early%20Intervention%20AD.pdf</ref><ref>Section C2 [http://www.alzheimers.ca/english/newsevents/conference-programdetails.htm Alzheimer's Society of Canada]</ref>


== References ==
== References ==

Revision as of 18:08, 16 March 2008

Cognitive therapies for dementia are starting to gain some momemtum. Improved clinical assessment in early stages of Alzheimer's desease and other forms of dementia, increased cognitive stimulation of the elderly, and the prescription of drugs to slow cognitive decline have resulted in increased detection in the early stages[1][2][3]. Although the opinions of the medical community are still apprehensive to support cognitive therapies in dementia patients, recent international studies have started to create optimism. [4]

Classification and efficacy of the different therapies

Interventions are used as an adjunct to pharmaceutical treatment and can be classified within behavior, emotion, cognition or stimulation oriented approaches. Research on efficacy is reduced.[5]

Behavioral interventions

Behavioral interventions attempt to identify and reduce the antecedents and consequences of problem behaviors. This approach has not shown success in the overall functioning of patients,[6] but can help to reduce some specific problem behaviors, such as incontinence.[7] There is still a lack of high quality data on the effectiveness of these techniques in other behavior problems such as wandering.[8][9]

Emotion-oriented interventions

Emotion-oriented interventions include reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration or snoezelen, and simulated presence therapy. Supportive psychotherapy has received little or no formal scientific study, but some clinicians find it useful in helping mildly impaired patients adjust to their illness.[5] Reminiscence therapy (RT) involves the discussion of past experiences individually or in group, many times with the aid of photographs, household items, music and sound recordings, or other familiar items from the past. Although there are few quality studies on the effectiveness of RT it may be beneficial for cognition and mood.[10] Simulated presence therapy (SPT) is based on attachment theories and is normally carried out playing a recording with voices of the closests relatives of the patient. There is preliminary evidence indicating that SPT may reduce anxiety and challenging behaviors.[11][12] Finally, validation therapy is based on acceptance of the reality and personal truth of another's experience, while sensory integration is based on exercises aimed to stimulate senses. There is little evidence to support the usefulness of these therapies.[13][14]

Cognition-oriented treatments

The aim of cognition-oriented treatments, which include reality orientation and cognitive retraining is the restoration of cognitive deficits. Reality orientation consists in the presentation of information about time, place or person in order to ease the understanding of the person about its surroundings and his place in them. On the other hand cognitive retraining tries to improve impaired capacities by exercitation of mental abilities. Both have shown some efficacy improving cognitive capacities,[15][16] although in some works these effects were transient and negative effects, such as frustation, have also been reported.[5] Some of the programms inside this approach are fully or partially computerized, such as the Cognitive Retention Therapy method.[17][18]

Stimulation-oriented treatments

Stimulation-oriented treatments include art, music and pet therapies, exercise, and any other kind of recreational activities for patients. Stimulation has modest support for improving behavior, mood, and, to a lesser extent, function. Nevertheless, as important as these effects are, the main support for the use of stimulation therapies is the improvement in the patient daily life routine they suppose.[5]

Summary of article by the American Journal of Psychiatry[19]

Out of 1632 total studies reviewed roughly 10% of them were included in the review. Objective was to determine the level of quality of the studies and the effectiveness of the results. Main theories of the studies explored were as follows.

  • Reminiscence Therapy - using household materials, family pictures and old newspapers to stimulate memories and hopefully have the participant share their experiences.

Results were dependent on reality orientation and were largely insignificant.

  • Validation Therapy - Based on personal uniqueness, promotes validating feelings of unfinished conflicts.

Results were inconclusive and insignificant.

  • Reality Orientation Therapy - Uses reminders about information such as day, time and location.

Results were insignificant.

  • Cognitive Stimulation Therapy - Uses information processing.

Results varied but were very positive in improving aspects of neuropsychiatric symptoms immediately and for many months after. Also improved mood, and delayed institutionalization.

  • Other dementia-specific therapies - “individualized special instruction” and “self-maintenance therapy”

Results may have been a product of environment but concluded an improvement to behavior and depression.

  • Non-dementia-specific therapies - Included many different varieties of treatments.

Most were inconclusive. Positive results were achieved using ‘life review, sensory stimulation’ and other personalized techniques.

  • Music Therapy - Helps reduce agitation and improve behavior during sessions and immediately after, however no long term benefits.
  • Snoezelen therapy - Possible improvement in disruptive behavior during sessions, effects are only apparent for a short time after.
  • Other sensory stimulation - Calming effects during sessions, no long term usefulness.
  • Simulated presence therapy - Possible reduction in agitation, no other real benefits.
  • Therapeutic activity programs - Results varied but overall were inconsistent and inconclusive with no real benefits.
  • Montessori activities - No changes realized.
  • Physical exercise - No changes realized.
  • Social interaction - Possible improvement in neuropsychiatric symptoms in some participants.
  • Decreased sensory stimulation - No real benefits.
  • Environmental Manipulation - Changing the visual environment, adding or removing mirrors, signposting, unlocking doors and other environmental manipulations such as group living.

Results showed a possible reduction in agitation and improvement with orientation, with no other real benefits.

  • Other studies focused on psychoeducation of Staff and family members ability to manage behavioral problems.

Results showed individual education was more effective then groups in being useful to treat neuropsychiatric symptoms.

Conclusions

The article concluded:

"Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms. Lack of evidence regarding other therapies is not evidence of lack of efficacy. Conclusions are limited because of the paucity of high-quality research (only nine level-1 studies were identified). More high-quality investigation is needed."


References

  1. ^ http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=2816&nbr=2042
  2. ^ http://findarticles.com/p/articles/mi_m0857/is_11_12/ai_n17215917
  3. ^ http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec4.html
  4. ^ {cite journal PMID: 16228161}
  5. ^ a b c d "Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias" (PDF). American Psychiatric Association. October 2007. doi:10.1176/appi.books.9780890423967.152139. Retrieved 2007-12-28. Cite error: The named reference "pracGuideAPA" was defined multiple times with different content (see the help page).
  6. ^ Bottino CM, Carvalho IA, Alvarez AM; et al. (2005). "Cognitive rehabilitation combined with drug treatment in Alzheimer's disease patients: a pilot study". Clin Rehabil. 19 (8): 861–9. PMID 16323385. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  7. ^ Doody RS, Stevens JC, Beck C; et al. (2001). "Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 56 (9): 1154–66. PMID 11342679. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  8. ^ Hermans DG, Htay UH, McShane R (2007). "Non-pharmacological interventions for wandering of people with dementia in the domestic setting". Cochrane Database Syst Rev (1): CD005994. doi:10.1002/14651858.CD005994.pub2. PMID 17253573.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Robinson L, Hutchings D, Dickinson HO; et al. (2007). "Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review". Int J Geriatr Psychiatry. 22 (1): 9–22. doi:10.1002/gps.1643. PMID 17096455. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  10. ^ Woods B, Spector A, Jones C, Orrell M, Davies S (2005). "Reminiscence therapy for dementia". Cochrane Database Syst Rev (2): CD001120. doi:10.1002/14651858.CD001120.pub2. PMID 15846613.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Peak JS, Cheston RI (2002). "Using simulated presence therapy with people with dementia". Aging Ment Health. 6 (1): 77–81. doi:10.1080/13607860120101095. PMID 11827626.
  12. ^ Camberg L, Woods P, Ooi WL; et al. (1999). "Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease". J Am Geriatr Soc. 47 (4): 446–52. PMID 10203120. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  13. ^ Neal M, Briggs M (2003). "Validation therapy for dementia". Cochrane Database Syst Rev (3): CD001394. doi:10.1002/14651858.CD001394. PMID 12917907.
  14. ^ Chung JC, Lai CK, Chung PM, French HP (2002). "Snoezelen for dementia". Cochrane Database Syst Rev (4): CD003152. PMID 12519587.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Spector A, Orrell M, Davies S, Woods B (2000). "WITHDRAWN: Reality orientation for dementia". Cochrane Database Syst Rev (3): CD001119. doi:10.1002/14651858.CD001119.pub2. PMID 17636652.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ Spector A, Thorgrimsen L, Woods B; et al. (2003). "Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial". Br J Psychiatry. 183: 248–54. PMID 12948999. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  17. ^ http://www.elderwise.ca/Early%20Intervention%20AD.pdf
  18. ^ Section C2 Alzheimer's Society of Canada
  19. ^ American Journal of Psychiatry
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