Psychological and Behavioural Interventions in Dementia

Question 1

What are the main non-pharmacological treatment strategies used in dementia?

Answer 1

▪️ Cognitive interventions
▪️ Exercise
▪️ Social activity
▪️ Technology

Question 2

What are the main target symptoms on non-pharmacological dementia interventions?

Answer 2

▪️ Cognition
▪️ Depression
▪️ Other neuropsychiatric symptoms (e.g., agitation)
▪️ Activities of daily living
▪️ Quality of life

Question 3

What are the main potentially modifiable risk factors for dementia?

Answer 3

▪️ Hearing loss
▪️ Smoking and alcohol
▪️ Depression
▪️ Social isolation
▪️ Physical inactivity
▪️ Obesity and diabetes
▪️ Less education

Question 4

What percentage of dementia is thought to be attributable to potentially modifiable risk factors?

Answer 4

40%

Question 5

What is the evidence for exercise interventions for preventing dementia?

Answer 5

▪️ 30-40% reduced in risk in those who exercise more
▪️ Improved memory in MCI?
▪️ BUT less evidence for its benefits on cognitive function in healthy older adults

Question 6

What is the evidence for cognitive activity and reserve for preventing dementia?

Answer 6

▪️ High engagement in mentally-stimulating activities = protective
▪️ More education = better able to compensate for effects of dementia

Question 7

What is the evidence for social engagement for preventing dementia?

Answer 7

Risk of incident dementia increased for those with:
▪️ limited participation in social activities
▪️ less frequent social contact

Question 8

Does cognitive training work in older adults?

Answer 8

▪️ Small improvements in trained domains at 2 years, particularly reasoning and memory
▪️ Benefits in ADLs, EF, and verbal learning
▪️ Small but significant effect?

Question 9

Does cognitive training work in dementia?

Answer 9

▪️ Limited evidence of efficacy on general cognition
▪️ BUT small number of studies
▪️ Potentially beneficial within trained cognitive domains such as episodic memory and EF - need to be more specific?

Question 10

What might be the best options for cognitive training interventions going forward?

Answer 10

▪️ Target working memory with chunking training - improves general cognition and MMSE
▪️ Online interventions
▪️ Combine with physical training

Question 11

What does NICE recommend for cognitive interventions in mild/moderate dementia?

Answer 11

Cognitive stimulation therapy - has the largest literature base

▪️ For all types of dementia
▪️ Structured group programme

Question 12

What are the benefits of cognitive stimulation?

Answer 12

▪️ Improved general cognition (e.g., MMSE) - active controls show significant but less impressive improvements
▪️ Group maintenance CS benefits QoL and ADL (group level)

BUT individualised CS shows no improvement in cognition or QoL - is it the social component?

Question 13

When might cognitive rehabilitation be used?

Answer 13

In mild/moderate dementia for those with specific functional goals

Improvements in participant and carer rated goal attainment but not secondary outcomes such as QoL, mood, and cognition?

BUT very expensive!

Question 14

What are the main limitations of the literature on cognitive approaches to dementia?

Answer 14

▪️ Small number of studies
▪️ Heterogeneity of methods
▪️ Inadequate controls
▪️ Inadequate blinding?
▪️ What is clinically significant?

Question 15

How has high intensity exercise been found to change the brain?

Answer 15

Promotes hippocampal neurogenesis

Question 16

What is the evidence for exercise in dementia?

Answer 16

▪️ Inconsistent evidence for effect on cognition
▪️ No clear evidence for NPS
▪️ BUT beneficial effect on ADLs and functioning!

Question 17

What is the DAPA trial and what did they find?

Answer 17

▪️ Dementia and Physical Activity trial
▪️ Exercise programme might worsen cognitive impairment but difference is small and importance in unclear

Question 18

What does social support in early stage dementia been show to do?

Answer 18

Improve QoL and depression

Question 19

What is the current evidence for non-pharmacological treatment of depression and anxiety in dementia?

Answer 19

CBT, interpersonal therapy or counselling are effective in slightly reducing depressive symptoms - better than antidepressants?

Question 20

What is used to assess psychopathology in dementia?

Answer 20

The Neuropsychiatric Inventory

(rates presence of symptom, severity, and caregiver distress)

Question 21

How can we best treat agitation in dementia?

Answer 21

▪️ Drugs appear pretty ineffective - antipsychotics primarily for sedation?
▪️ Risperidone if very severe
▪️ Increased focus on person centred psychosocial care
▪️ Dementia care mapping - WHY are they agitated?
▪️ Music therapy and activities?

Question 22

What is the best approach to apathy in dementia?

Answer 22

▪️ ‘Therapeutic activities’ both non-tailored and tailored for individual interests or skills
▪️ Antipsychotics combined with social activity and/or exercise

Question 23

What outcomes are associated with caring for people with dementia?

Answer 23

▪️ 40% have depression or anxiety
▪️ Worse physical health, more absences from work, and lower health related QoL

Question 24

What can interventions can we offer for carers of people with dementia?

Answer 24

▪️ Behaviour management skills shown to help physical health and depression
▪️ Possible roles for skills training, education, enhanced support and collaboration with professionals?

FOCUS ON CHANGING HOW THEY ACT OR REACT, ACKNOWLEDGING THE PwD USUALLY CANNOT CHANGE THEMSELVES

Question 25

How might technology be useful in the management of people with dementia?

Answer 25

▪️ Computerised and VR diagnostic assessment
▪️ Environmental and physiological sensors for monitoring progression, vitals, etc
▪️ Assistive technology such as cognitive aids, ADL assistance, and safety
▪️ Therapeutic technology (e.g., communication, companionship, activity)
▪️ Carer supportive technology (e.g., telemedicine, online information, peer support)