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Evidence-Based Non-Pharmacological Therapies for Early-Stage Dementia: Implications for Clinical Practice


Evidence-Based Non-Pharmacological Therapies for Early-Stage Dementia: Implications for Clinical Practice Presented by: Sandy C. Burgener, PhD, GNP BC, FAAN – PowerPoint PPT presentation

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Title: Evidence-Based Non-Pharmacological Therapies for Early-Stage Dementia: Implications for Clinical Practice

Evidence-Based Non-Pharmacological Therapies for
Early-Stage Dementia Implications for Clinical
  • 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 Alzheimers
    Association, Chicago, Illinois

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

Criteria for Grading the Strength of the
  • 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-Pharmacologica
l 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 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
  • Slowing of cell death.

Plasticity Theory (Contd)
  • 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 interactions
  • Varied, intense stimuli
  • Novel stimuli

Exercise Interventions n11
  • 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
  • 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
  • Increased dopamine levels in the brain
  • Increases 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 n41
  • 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
  • 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

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

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

Limitations of Cognitive Training Research
  • Lack of consistency regarding content of
  • 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 n13
  • 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
  • Age-matched control groups lacking
  • Participation is terminated at the end of the
    formal sessions, with the exception of the
    Alzheimers Café in the Netherlands.

Exemplar Programs n14
  • 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
  • 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 management
  • Cognitive exercises
  • Cognitive-behavioral therapies
  • Reality orientation

Components of Multi-Modal Interventions (Contd)
  • Nutritional intervention (high-protein
  • Conversational stimulation
  • Volunteer service or meaningful community
  • College course
  • Recreational and social therapies
  • Family involvement and therapies

Health Promotion Interventions n32
  • 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.

Health Promotion Interventions (Contd)
  • 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 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
  • 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 DementiaNon-Pharmacological
Treatment Protocol
  • Multi-modal intervention programs
  • Physical exercise, preferably aerobic or mindful
  • 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
  • Support group participation (continuous, not
  • Sleep hygiene programs, such as NITE-AD

Early-Stage DementiaNon-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 Program
  • Center for Positive Aging Buettner
  • Minds in Motion and Lunch Learn Burgener
  • Brookdale-funded programs Early-Memory Loss

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
  • Positive reputation Word of mouth

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

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

  • 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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    brain plasticity after TBI. Brain Injury, 17,
  • Bach-y-Rita, P. (2003b). Late postacute
    neurologic rehabilitation neuroscience,
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    Physical Medicine and Rehabilitation, 84,
  • Black, J.E., Sirevaag, A.M., Greenough, W.T.
    (1987). Complex experience promotes capillary
    formation in young rat visual cortex.
    Neuroscience Letters, 83, 351-355.
  • Boeve, B.F. (2005). Clinical, diagnostic, genetic
    and management issues in dementia with Lewy
    bodies. Clinical Science, 109, 343-354.
  • Briones, T.L., Suh, E., Jozsa, L., Rogozinska,
    M., Woods, J., Wadowska, M. (2005). Changes in
    number of synapses and mitochondria in
    presynaptic terminals in the dentate gyrus
    following cerebral ischemia and rehabilitation
    training. Brain Research, 1033, 51-57.
  • Briones, T.L., Suh, E., Hattar, H., Wadowska,
    M. (2005). Dentate gyrus neurogenesis after
    cerebral ischemia and behavioral training.
    Biological Research in Nursing, 6(3), 167-179.
  • Buettner, L.L. (2006). Peace of mind a pilot
    community-based program for older adults with
    memory loss. American Journal of Recreation
    Therapy, 13(2), 1-7.

  • Buettner, L.L., Fitzsimmons, S. (2006).
    Recreation clubs an outcome-based alternative to
    daycare for older adults with memory loss.
    Activities Directors Quarterly for Alzheimers
    Other Dementia Patients, 7(2), 10-20.
  • Burgener, S.C., Yang, Y., Gilbert, R.,
    Marsh-Yant, S. (2008). The effects of a
    multi-modal intervention on outcomes of persons
    with early-stage dementia. American Journal of
    Alzheimers Disease and Other Dementias, 23(4),
  • Lazarov, O., Robinson, J., Tang, Y. P., Hairston,
    I. S., Korade-Mirnics, Z., Lee,
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    reduces abeta levels and amyloid deposition in
    transgenic mice. Cell, 120, 701-713.
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    Vitiello, M.V., Teri, L. (2005). Nighttime
    insomnia treatment and education for Alzheimers
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    years of exercise, language, and social
    interventions on Alzheimers discourse. Journal
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    Greenough, W.T. (1988). Direct evidence that
    complex experience increases capillary branching
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