Day: February 23, 2015

If the drugs don’t always work, why don’t we consider more seriously cognitive stimulation therapy?

Shibley Rahman 0 Comments

dementia CST

The transfer of an individual living with dementia into a residential setting, at worst, can be associated with an sensorily-unstimulating environment, as well as reduced sensorimotor and cognitive stimulation, social interactions, and physical activity.

Starting from the 1960s, various non-pharmacological treatments for patients with dementia have been proposed, in order to improve cognitive skills and quality of life, to reduce behavioural disturbances and maximise function in the context of existing deficits.

There is a long tradition of psychological therapies for people with dementia, but they had seldomly been rigorously evaluated, making it difficult for commissioners and providers to plan services from a solid evidence base, and also making it difficult to draw comparisons with pharmacological interventions. However, Cochrane reviews on non-pharmacological interventions have previously highlighted the insufficiency of the available evidence.

A recent Cochrane review on cognitive stimulation (Woods et al., 2009) combined the data from nine randomised controlled trials. It found that, oer and above any medication effects, and some studies suggest that the benefits may be maintained for over a year. Recently, Apóstolo and colleagues (2014) reported that cognitive stimulation therapy had significantly improved cognition, explaining the 15.7% variability, but there was no statistical evidence of its effectiveness on depressive symptoms. This improvement was not affected by the baseline level of dependence-independence in activities of daily living.

Conceptualising dementia within the framework of a disability model highlights the distinction between the underlying impairment, resulting from pathological changes, and the resulting limitations on engaging in activity (disability) and restrictions on social participation (handicap).

Cognitive impairment is a defining feature of dementia caused by neurodegenerative conditions including the dementias. Family caregivers are also affected because of the practical impact of cognitive problems on everyday life and the strain and frustration that often result. It has been suggested that rehabilitation provides a useful overarching conceptual framework for the care and support of people with dementia and for the design of interventions to meet their needs. Recreational activities (e.g., crafts, pets) and art therapies (e.g., music, dance, art) have been often proposed as non-pharmacological treatments in dementia, and are widely utilised in residential settings.

Cognition-focused interventions as a group fall under the broader umbrella of non-pharmacological interventions. Cognition-focused interventions can be broadly defined as interventions that directly or indirectly target cognitive functioning as opposed to interventions that focus primarily on all aspects of whole person care – i.e. behavioural, emotional or physical function.

An increasing number of dementia studies describe their intervention as ‘cognitive stimulation’. Clare and Woods (2008) provided a definition which stated that cognitive stimulation:

  • targets cognitive and/or social function;
  • has a social element — usually in a group or with a family care-giver;
  • includes cognitive activities which do not primarily consist of practice on specific cognitive modalities;
  • may be described as reality orientation sessions or classes.

Several types of cognition-based interventions have been described. The potential benefits of non-specific stimulation of cognitive functioning for people with dementia have long been recognised. These interventions typically involve engaging the person with dementia in a range of general activities and discussions, are commonly conducted in groups and are aimed at general enhancement of cognitive and social functioning.

Cognitive stimulation typically involves a set of tasks designed to reflect cognitive functions such as attention, memory, language, and problem solving, combined with a reality orientation session. This training takes place in individual or group sessions with a range of difficulty levels. The fundamental assumption is that practice with specific cognitive function tasks may improve, or at least maintain, functioning in a given domain and that any effects of practice will generalise and induce a general improvement of cognitive and social functioning. There is some additional evidence that these interventions can decrease behavioural problems and improve mood.  Other authors have also reported positive results for training of basic activities of daily living.

However, some treatment guidelines have been highly critical of cognitive stimulation or training interventions in dementia in view of the risk that cognitive gains may be achieved at the expense of reduced wellbeing and adverse effects.

So, the burning question is: if the drugs don’t always work, why don’t we consider more seriously cognitive stimulation therapy? The answer is possibly in large part cultural and social. That is, medical professionals, large charities and the media, in cahoots in Big Pharma, don’t want to give up their traditional power base in treatment. Look for example at Julianne Moore on the red carpet of the Oscars last night talking about how ‘there is no treatment for dementia’. But almost certainly we don’t have that the correct organisational structures in place. There is regulatory capture, which means that drugs can rarely become recommended despite modest effects, but there is virtually no head to head comparison of the cost efficacy or resource allocation consequences of medication vs psychosocial approaches. There is no clear infrastructure subserving ‘social prescribing’, where GPs can easily prescribe such treatments, yet, in England, despite the fact that this could potentially save the NHS a lot of money, and see an improvement in wellbeing in many of its patients.

There are powerful forces at work. You have been warned.

 

References

Apóstolo JL, Cardoso DF, Rosa AI, Paúl C. The effect of cognitive stimulation on nursing home elders: a randomized controlled trial. J Nurs Scholarsh. 2014 May;46(3):157-66. doi: 10.1111/jnu.12072. Epub 2014 Mar 5.

Clare L, Woods RT. 2004. Cognitive training and cognitive rehabilitation for people with early stage Alzheimer’s disease: a review. Neuropsychol Rehabil 14: 385–401.

Woods B, Spector A, Orrell M, Aguirre E. 2009. Cognitive stimulation for people with dementia (review) The Cochrane Database of Systematic Reviews Chichester: Wiley

Person-centred care’s focus shouldn’t be profit generation. But it does deserve attention in dementia.

Shibley Rahman 0 Comments

jigsaw

Often ‘person centred care’ can be synonymous with profit generation in the private sector, hence a focus more on purses than persons as once quipped by Kate Swaffer, but it is a methodology whose roots warrant scrutiny. It gets away from the idea of patients as fodder for biochemical and neuroimaging investigations, with not much to be added by professionals. The meme that ‘there is no treatment for treatment’ plays very nicely into the medical model of dementia. However, taking a more social or psychological approach, you get a totally different perspective.

The complexity of dementia demands comprehensive individualised care that addresses physical, psychological, social, and legal issues of the persons with dementia as well as their caregivers Recently, person-centred care (PCC) has become valued in the field of dementia care. Nonetheless, PCC has been considered to be rather abstract or vague, partly as many publications are based on personal opinion, anecdotal evidence and/or theoretical constructs only.

Person-centred care is increasingly considered essential, whereas purpose-built facilities and environmental design are reported to enhance safety and to have a positive effect on behaviour. Within the UK National Health Service (NHS), the provision of person-centred services for individuals with acquired neurological conditions has been widely promoted. Services provided for people with dementia have been criticised in reports such as the UK Audit Commission’s ‘Forget-Me-Not’ which found them inflexible rather than person-centred, with poor integration of health and social services (Audit Commission, 2000).

To inform and direct service development for this clinical population, the National Service Framework for Long Term Neurological Conditions (Department of Health, 2005) originally set out quality requirements for improving PCC. PCC in rehabilitation has been defined as an approach that facilitates participation in decision making and goal-setting, client-centred education, client evaluation of outcomes, family involvement, emotional support, physical comfort, co-ordination and continuity.

Progressive deterioration in cognition, function, and behaviour make people with dementia increasingly dependent on others for normal activities of daily living. A person-centred approach is uniquely enmeshed with the pivotal importance of dignity. Dignity of identity represents a person’s subjective experiences of dignity and is related to integrity, autonomy, self-respect and social relations. This kind of dignity may be taken away or threatened by external events or by the acts of other people, for example, if an individual is humiliated or treated as an object.

Ideas about person-centred caregiving have been discussed by several authors within the gerontology literature. In the United Kingdom and elsewhere, Kitwood’s work with residents with dementia has been influential (Kitwood, 1997). This approach reconceptualises the dementias as involving processes not focused on pathology but on the social psychology of the person affected. An individual’s characteristics, including such things as the past, roles, personality, values, self-worth, spirituality, and so on, combined and defined through years of living, are often used to identify personhood at a higher level. Kitwood’s research places an emphasis on the belief that older adults should be treated as social beings worthy of relationship. Within each human being, regardless of cognitive impairments, is the desire to be respected and connected with others.

Dementia-care mapping (DCM) is a person-centred, multi-component intervention developed by the Dementia Research Group at Bradford University in the UK and is based on Kitwood’s social-psychological theory of personhood in dementia. DCM is a systematic approach for the assessment of PCC that can help to identify factors influencing behavior and to create individual person-centred care plans. DCM can also be used as an assessment for residents’ well-being.

As recent research investigations in nursing homes have emphasised, the personal relationships direct care workers forge with individual residents appear central to quality of care or quality of life outcomes on the part of residents. Evidence for improved outcomes for people with dementia through provision of person-centred care and dementia-care mapping thus far has been largely observational. However, taking a more robust scientific approach (it is mooted), person-centred care and dementia-care mapping both seem to reduce agitation in people with dementia in residential care.

Nursing staff’s person-centredness does play a modest role in relation to job characteristics and job-related well-being. Flexibility, possibly, is an essential ingredient of personcentered care. This person-centred care philosophy attempts to adapt care to the needs, preserved abilities, personality, habits, preferences, and cognitive, sensory, and physical limitations of the person with dementia. In order to do so, caregivers often have to adapt schedules, decision-making processes, and environments to the needs of the person with dementia, thus requiring a great degree of flexibility. It is currently felt that DCM is a “cost-neutral” intervention. It effectively reduces outpatient hospital appointments compared to usual care. Other considerations than costs, such as nursing homes’ preferences, may determine whether they adopt the DCM method.

The concept of person-centred care has recently been expanded to include “family-centred care” which acknowledges the important role of the family or other loved ones in the patient’s final days. Whereas experiences of having a relative with dementia in long-term care have been explored, the experience of spouses specifically is relatively sparse. As a contrast, staff on standard care wards often do not routinely complete personal profile documentation with family carers.

There has been – on the whole – a welcome recognition of the importance of a well-trained workforce to support people with dementia living in care homes. However, there is an emerging between the interventions that are routinely available and being commissioned, and the evidence base indicating benefit, arguably. In a way, person-centred care and family centred-care are not especially different what excellent caregivers, including professionals, should have been doing. Whilst nobody ‘owns’ the agenda, it would be a real shame if the marketing and corporatism o this ideology overplayed their hands at the expense of their clinical underpinnings.
References

Audit Commission. Forget Me Not: Mental Health Services for Older People. London: Audit Commission, 2000.

Department of Health (2012b). Compassion in practice: Nursing, midwifery and care staff. Our vision and strategy. London: Department of Health.

Kitwood, T. (1997). The experience of dementia. Aging & Mental Health, 1, 13–22.