Dementia: A Neurocognitive Disorder   16  

Kathleen Fletcher

OVERVIEW

Dementia is most commonly defined as a clinical syndrome of cognitive decline. The term dementia was eliminated and replaced with “major or minor neurocognitive disorder” in the latest Diagnostic and Statistical Manual on Mental Health Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). It was felt that the term dementia was stigmatizing and the focus should be on decline rather than deficit. Because these changes are confusing to many health care professionals and the term dementia remains established in the literature, the terms dementia and neurocognitive disorder are used interchangeably in this chapter. In addition to disruptions in cognition, dementia is associated with a gradual decline in function and changes in mood and behavior.

There are many causes of dementia and dementia-like presentations. Differentiating these changes early in the course of illness is important because condition-specific assessment, monitoring, and management strategies can be employed. Differential diagnoses among conditions that cause cognitive impairment are confounded by the fact that these conditions may coexist and disparate neurocognitive disorders may be similarly clinically expressed.

Major goals in the clinical approach to a person presenting with cognitive impairments are identification and resolution of potentially reversible conditions (e.g., delirium, depression), recognition, and control of comorbid conditions, early diagnosis and management of a neurocognitive disorder, and the provision of caregiver support. The focus of this chapter is on assessment and management of the major neurocognitive disorders.

BACKGROUND AND STATEMENT OF PROBLEM

Global estimates reflect that 44.4 million people have dementia today, which will increase to 75.6 million by 2030 and 135.5 million by 2050 (Alzheimer’s Disease International, 2013). The rapid growth of the older adult population in the United States is associated with a significant increase in the prevalence of dementia. Dementia affects about 11% of individuals 65 years and older (Alzheimer’s Association, 2015). The prevalence increases exponentially with age, rising to nearly 32% in individuals 85 years and older (Hebert, Weuve, Scherr, & Evans, 2013). More than 4.7 million individuals in the United States have the most common form of dementia, Alzheimer’s disease (AD), a number that is projected to increase to 13.8 million by 2050 (Hebert et al., 2013).

This chapter discusses the most common forms of progressive dementia, AD, vascular dementia (VaD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD). Less common, though not less significant, is progressive dementia associated with Parkinson’s disease (PDD), dementias associated with HIV, and Creutzfeldt–Jacob disease.

AD, the most common form of dementia, accounts for more than 80% of all cases. A chronic neurodegenerative disease, first described by Alos Alzheimer in 1907, it is characterized by neurofibrillary plaques and “tangles” in the brain. The extracellular accumulation of amyloid beta proteins in the neuritic plaques is one of the hallmarks of AD (Ariga, Miyatake, & Yu, 2010). The variation in the clinical presentation of the disease depends on the area of the brain that is affected. Classic features of AD include progressive loss of memory, deterioration of language and other cognitive functions, decline in the ability to perform activities of daily living (ADL), and changes in personality and behavior and judgment dysfunction (Castellani, Rolston, & Smith, 2010). Mild cognitive impairment (MCI) represents a transitional state between healthy aging and dementia and is characterized by cognitive impairment out of proportion to the age of the individual yet the individual does not meet the criteria for dementia (Yanhong, Chandra, & Venkitesh, 2013). Incidence rates of MCI are 51 to 76.8 per 1,000 person-years with a higher incidence in advanced age, lower education, and hypertension (Luck, Luppa, Briel, & Riedel-Heller, 2010). About 35% of MCI patients progress to AD, with an annual conversion rate of 5% to 10% (Mitchell, 2009). Cerebrospinal fluid (CSF) biomarkers’ performance is the most convenient test predicting conversion yet it remains suboptimal (Ferreira et al., 2014).

VaD, sometimes referred to as vascular cognitive impairment (VCI) and previously known as multi-infarct dementia (MID), refers to dementia resulting from cerebrovascular disease. It is the second most common cause of dementia among older adults and represents approximately 20% of all cases of dementia in the United States (Román, 2003). The link between AD and VaD is strong yet not entirely clear (de la Torre, 2012). There are many types of VaD and lumping them under a single rubric causes some diagnostic confusion (Kirshner, 2009). The onset of VaD is usually more acute than AD and the diagnosis of VaD is based on the association between a cerebrovascular event and the onset of clinical features of dementia, including evidence of focal deficits, gait disturbances, personality and mood changes, and impairments in executive function. As compared with AD, memory may not be impaired or is more mildly affected. It is not uncommon that AD and VaD pathology coexist and this, often referred to as a mixed dementia, is likely to increase as the population ages (Langa, Foster, & Larson, 2004).

DLB accounts for about one in 25 diagnosed cases of dementia (Vann Jones & O’Brien, 2014). DLB is a neurodegenerative dementia that results when Lewy bodies form in the brain. Lewy bodies are pathological aggregations of alpha-synuclein found in the cytoplasma of neurons (McKeith et al., 2003). Clinical features include cognitive and behavioral changes in combination with features of parkinsonism. Disorders of executive function occur early. Hallucinations, visual–spatial disturbances and sleep disorders are prominent. Rigidity and unsteady gait are common. Many (but not all) patients with PDD develop a dementia years after the motor symptoms appear. Distinctions have been made clinically between DLB and the dementia associated with PDD based on the sequence of the appearance of symptoms over the time course. In PDD, motor symptoms precede cognitive impairment, while DLB begins with fluctuations in cognition (Mayo & Bordelon, 2014). DLB and PDD may represent the same pathological process along a disease spectrum (Hanson & Lippa, 2009).

FTD, with a prevalence of 15 per 100,000, refers to a group of progressive brain diseases with clinical manifestations dominated by behavioral changes and/or impairments in language (Riedl, MacKenzie, Forsti, Kurz, & Diehl-Schmid, 2014). A growing body of evidence indicates that FTD and amyotrophic lateral sclerosis (ALS) share some clinical, pathological, and molecular features as part of a common neurogenerative spectrum disorder (Gascon & Gao, 2014).

The National Alzheimer’s Project Act of 2011 mandates a national plan to address AD and related dementias (specifically VaD, mixed dementia, DLB, and FTD; Montine et al., 2014).

ASSESSMENT OF THE PROBLEM

Goals of Assessment

Early identification of cognitive impairment is the most important goal in assessment. Cognitive impairment resulting from conditions like dementia, delirium, or depression represents critically serious pathology and requires urgent assessment and tailored interventions. Yet, diminished or altered cognitive functioning is often perceived by health care professionals as a normal consequence of aging and opportunities for timely intervention are too often missed (Milisen, Braes, Fick, & Foreman, 2006). Although distinctions have been made comparing the clinical features of the common cognitive impairments associated with delirium, dementia, and depression, this is difficult to do clinically because these conditions often coexist and older adults can demonstrate atypical features in any of these conditions.

The second most important assessment goal is to identify a potentially reversible primary or contributing cause of a cognitive impairment. The common causes of reversible cognitive impairment (delirium) in the older adult are covered in Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment.”

History Taking

Complaints from the patient or observations made by others of memory loss, problems with decision making and/or judgment, or a decline in function in an activity of daily living should alert the health care professional that a progressive form of dementia might exist. Collecting an accurate history is the cornerstone to the assessment process, yet this obviously is a challenge in the individual presenting with cognitive impairment. The assessment domains covered in history taking include functional, cognitive, and behavioral queries and observations. The history-taking process involves first interviewing the patient followed, perhaps, by clarifying, elaborating, and validating information with the family or others familiar with the capabilities and expressions of the patient. An informant questionnaire on cognitive decline can also provide utility with the commonly used tool being the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Although the accuracy is reasonable its use alone may result in misdiagnosis or false reassurance (Quinn et al., 2014), underscoring the need for a comprehensive evaluation.

Even when a diagnosis of dementia has been made, it is often not communicated well across care settings. The easiest way to increase recognition of dementia in older hospital patients is to add the items “severe memory problems,” “Alzheimer’s disease,” and “dementia” to the list of diseases and conditions patients and families are routinely asked about on intake forms and in intake interviews.

Functional Assessment

Dementia is characterized by deterioration in the ability to perform ADL. Because cognitive assessment can be embarrassing and/or threatening it may be more respectful to initiate the conversation around the patient’s functional domain. Asking the patient to elaborate on his or her functional abilities in ADL as well as instrumental activities of daily living (IADL) and eliciting any identified decline with specified chronology can provide some insight. The reader is referred to Chapter 6, “Assessing Cognitive Function” for a general approach and tools for functional assessment. Several functional tools have been tested specifically in individuals with dementia.

The Functional Activities Questionnaire (FAQ) is an informant-based measure of functional ability and has been recognized for its ability to discriminate early dementia. An informant, typically the primary caregiver, is asked to rate the performance of the patient in 10 different activities. The Functional Assessment Staging Test (FAST) has been used to effectively discriminate among normal cognition, MCI, and dementia and has proven to be useful in measuring functional performance (Rikkert et al., 2011; Teng et al., 2010). The Alzheimer’s Disease Cooperative Study (ADCS)–ADL inventory is a specific functional tool used primarily in clinical drug trials to assess and monitor patients with moderate to severe AD (Galasko et al., 1997). Clinical studies using this scale have indicated that cholinesterase inhibitors offer an effective approach to treating functional decline in certain forms of dementia (Potkin, 2002) and lower scores on ADCS-ADL are predictive of nursing home placement (Miller, Schneider, & Rosenheck, 2011). The patient’s daily caregiver is asked to rate the older adult’s usual performance on the more basic measures of function over the previous month to identify progression of functional decline. It has been recognized that individuals with a frontotemporal behavioral-variant form of dementia may have greater functional impairment than those with other forms of dementia (Lima-Silva, Bahia, Nitrini, & Yassuda, 2013). In addition to looking for potential treatments this rating helps to provide an explanation to the patient and family for advance care planning while the patient is still capable of decision making. As technology continues to advance, the manually based functional assessments may be replaced by technology-based ones (Lowe et al., 2013).

Cognitive Assessment

The cognitive domain is assessed as part of a broader mental status evaluation, the components of which are listed in Table 16.1. Although some of the parameters of a mental status evaluation (such as memory or cognition) might be measured with a standardized tool, such as the Mini-Mental State Exam (MMSE), others require specific inquiry or direct or indirect observation by the health care professional and/or caregiver. The measure of mood is totally subjective and is based on self-report status. The evaluation always provides the opportunity to identify sensory impairments (vision and hearing loss), which can further impact cognition, function, and behavior. There are a variety of tools for assessing cognitive impairment, some more sensitive to mild dementia and others to moderate to severe dementia.

TABLE 16.1

Components of Mental Status Evaluation

The gold standard of tools that measure cognition is the MMSE, which was developed over 30 years ago (Folstein, Folstein, & McHugh, 1975). Used extensively in clinical trials as well as in a variety of clinical settings, it is relatively easy to administer and score and can be used to assess cognitive changes over time. The annual rate of decline on the MMSE in AD is 3.3 points annually (Han, Cole, Bellavance, McCusker, & Primeau, 2000). The MMSE has established validity and reliability although concerns continue to be expressed by clinicians that it is time-consuming and in some circumstances the relevancy of selected questions has been raised. The MMSE score is strongly related to education with high false-positive rates for those with little education; predictive power is also significantly influenced by language (Parker & Philp, 2004). It is insensitive to executive dysfunction and has been criticized for a lack of sensitivity in detecting early or mild dementia (Liefer, 2003). As has been suggested with other measures of cognitive testing, the MMSE may have a cultural bias (Manly & Espino, 2004). Clinicians must remain aware that a high score on the MMSE does not rule out cognitive decline or the possibility of dementia particularly in high-functioning individuals with cognitive complaints (Manning, 2004). The tool is no longer in the public domain and copyright permission must be secured. A tool with comparable sensitivity and specificity for detecting dementia is the St. Louis University Mental Status Exam (SLUMS) and it is available for free (Tariq, Tumosa, Chibnall, Perry, & Morley, 2006).

Instruments, such as the Mini-Cog (Borson, 2003), Memory Impairment Screen (Buschke, 1999), and General Practitioner Assessment of Cognition (Brodaty, 2002), have all been recognized for utility, whereas the Clock Draw test (CDT, Shulman, 2000) and newer instruments, such as the Montreal Cognitive Assessment (MoCA, Nasrredine et al., 2005), have greater sensitivity, address frontotemporal executive function and have less educational and cultural bias (Ismail, Rajji, & Shulman, 2010). Unlike the more language-based tools described earlier, the CDT assesses cognition focused on executive function. A systematic review of the literature identified the CDT’s usefulness in predicting future cognitive impairment (Peters & Pinto, 2008). Scoring is based on the ability to free-hand draw the face of a clock, insert the hour numbers in the appropriate location, and then set the hands of the clock to the time designated by the examiner. The CDT is strongly correlated with executive function (i.e., the ability to execute complex behaviors and to solve problems) and is useful in the detection of mild dementia (Peters & Pinto, 2008). It also correlates moderately with driving performance, as the CDT score drops the number of driving errors increases (Freund, Gravenstein, Ferris, Burke, & Shaheen, 2005; Freund, Gravenstein, Ferris, & Shaheen, 2002).

A clinically useful tool that combines the CDT with measures of cognition (three-word recall) is the Mini-Cognitive (Mini-Cog; Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000). The Mini-Cog detected cognitive impairment in a community sample of predominately ethnic minority better than primary care physician assessment (84% vs. 41%) particularly in milder stages of the disease (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005).

A systematic review of the Mini-Cog for screening for dementia in primary care demonstrated that it was brief; easy to administer; clinically acceptable and effective; and minimally affected by education, gender, and ethnicity (Milne, Culverwell, Guss, Tuppen, & Whelton, 2008) with psychometric properties similar to the MMSE (Brodaty, Low, Gibson, & Burns, 2006).

Behavioral Assessment

Behavioral changes occur both in early-stage and throughout dementia (Kilik et al., 2008), and are also seen in MCI; commonly these include depression, anxiety, and irritability (Monastero, Mangialasche, Camarda, Ercolani, & Camarda, 2009). Regular assessment and monitoring can help identify the triggers of disruptive behavior and early manifestations of the behavior. Timely interventions that result in de-escalation of the behavior can help decrease the level of distress experienced both by the patient and caregiver. Behavioral management can help maintain functionality and safety. Commonly demonstrated behaviors are those associated with agitation and psychosis. Asking the patient about levels of restlessness, anxiety, and irritability is important, as at times these emotional/behavioral states occur even earlier than cognitive changes. Aggression, wandering, delusions and hallucinations, and resistance to care are manageable with nonpharmacological and pharmacological treatment options.

The literature on the link between psychosis and aggression in people with dementia is mixed (Shub, Ball, Abbas, Gottumukkala, & Kunik, 2010). The Neuropsychiatric Inventory (NPI, Cummings, 1994) measures frequency and severity of psychiatric symptoms and behavioral manifestations in individuals with dementia. The NPI takes about 10 minutes to administer during which the caregiver is asked screening and probing questions related to the presence and degree of behaviors such as agitation, anxiety, irritability, apathy, and disinhibition. The NPI also includes a measure of caregiver stress. It has established validity and reliability though it does not discriminate between disorder types (Lai, 2014).

Because as many as 50% of individuals with dementia have coexisting depressive symptoms (Lee & Lyketsos, 2003), it is important to conduct an adjunctive assessment of depression. Recognizing depressive symptoms in older adults is challenging and using an interviewer-rated instrument is recommended in addition to using clinical judgment (Onega, 2006). The Geriatric Depression Scale (GDS) is a screening instrument that takes only a few minutes to administer and is discussed along with appropriate depression-management strategies in detail in a Chapter 15, “Late-Life Depression.”

Referral of the patient to a neuropsychologist for more extensive neuro psychological testing is often indicated in order to provide more specific diagnostic information associated with neurodegenerative disease states and areas of brain dysfunction. This kind of assessment can identify subtle cognitive impairments in higher functioning individuals, distinguish MCI from dementia, and can provide direction and support for care providers and the family (Adelman & Daly, 2005).

Physical Examination and Diagnostics

Once the functional, cognitive, and behavioral domains in progressive dementia have been established through history taking of the patient and caregiver, a thorough review of systems is undertaken followed by the physical examination. The history-taking process narrows the differential diagnosis of reversible and irreversible causes for dementia. A thorough neurological and cardiovascular examination will help to specify the etiology of a single type or combined dementia, which will direct the need for laboratory and imaging tests. Cardiovascular findings, such as hypertension, arrhythmias, extra heart sounds or murmurs, along with focal neurological findings, such as weakness and sensory deficit, may favor a diagnosis of VaD, pathological reflexes, gait disorders, and abnormal cerebellar findings that may be indicative of AD, and parkinsonian signs that might indicate dementia associated with either Lewy bodies or PDD (Kane, Ouslander, Abrass, & Resnick, 2013).

There are no specific laboratory tests for the diagnosis of progressive dementia other than those that can primarily indicate a potentially reversible or contributing cause (see Table 16.1 and Chapter 17). The American Academy of Neurology (AAN) recommends two specific laboratory tests (thyroid function and B₁₂) in the initial evaluation of suspected dementia (Knopman et al., 2001). The AAN similarly recommends that all patients with suspected dementia have an MRI study or noncontrast CT as part of the initial workup. Once dementia has become clinically relevant and a cause apparent, there is no further diagnostic yield afforded by imaging.

Caregiver Assessment

It is important to remember that the caregiver is a patient too in that he or she suffers, as does the patient with dementia. Caregiver need and burden refer to the psychological, physical, and financial burden associated with caregiving. Caregivers are at risk of depression, physical illness, and anxiety (Cooper, Balamurali, & Livingston, 2007; Schoenmakers, Buntinx, & Delepeleire, 2010). Behavioral problems are determinants of burden yet feeling confident and positive self-efficacy can diminish caregiver burden (van der Lee, Bakker, Dunenvooden, & Droes, 2014). The Zarit Burden Interview (ZBI) can be used to identify the degree of burden experienced by the caregiver. The ZBI is a four-item screening followed by an additional 12 items; the test has good reliability and validity (Higginson, Gao, Jackson, Murray, & Harding, 2010). Administration of this tool to a community-dwelling caregiver can indicate the extent of impact caregiving has on the caregiver’s health, social and emotional well-being, and finances. The Modified Caregiver Strain Index (CSI) is another tool that has been used to identify families with caregiving concerns (Onega, 2008). There is a growing body of literature that describes the relationship between people with dementia and the family members who care for them (Ablitt, Jones, & Muers, 2009).

INTERVENTIONS AND CARE STRATEGIES

There is no cure for progressive dementia. The management of individuals with dementia requires pharmacological and nonpharmacological interventions.

Pharmacological Interventions

The goals of pharmacological therapy in dementia include preserving what the disease destroys in cognitive and functional ability, minimizing what the disease imposes in the way of behavior disturbances, and slowing the progression of the disease effects brought on by the destruction of neurons (Geldmacher, 2003). Nurses, regardless of whether they are the prescribers of drug therapy, need to be informed about the variety of drugs used in managing dementia and the evidence supporting their pharmacological approaches. Although there is substantial evidence that adults with mild to severe AD would benefit from drug therapy, there are no solid data in support for drug therapy for individuals with other forms of dementia (Schwarz, Froelich, & Burns, 2012).

Acetyl cholinesterase inhibitors (AChEIs) are the mainstay of treatment in AD. Three are currently available in the United States: donepezil hydrochloride (Aricept), rivistigmine tartrate (Exelon), and galantamine hydrobromide (Razadyne) with tacrine hydrochloride (Cognex)—the oldest and less favored drug taken off the market in 2013 because of its adverse effect on the liver and multiple daily dosing. A combination drug, memantine/donepezil (Namzaric), is also available. Cognitive improvements in patients with mild to moderate AD have been shown for all three of the AChEIs agents available in the United States (Tan et al., 2014). The acetyl cholinesterase inhibitors are safe and well tolerated; however, they may have gastrointestinal side effects (nausea, anorexia, and diarrhea). There is insufficient evidence at this time that pharmacological therapy for dementia can improve the quality of life for the patient and the caregiver and delay nursing home placement.

Memantine (Namenda), approved for moderate to severe dementia, has a different mechanism of action than the acetyl cholinesterase inhibitors. This N-methyl-D-aspartate receptor antagonist has neuroprotective effects that prevent excitatory neurotoxicity. Individuals with AD have improved cognition and behavior on this drug (McShane, Areosa Sastre, & Minakaran, 2006). Side effects of memantine, although uncommon, include diarrhea, insomnia, and agitation. In combined administration of cholinesterase inhibitors with memantine the research is mixed. Some studies (Atri et al., 2013; Riepe et al., 2007) demonstrated increased efficacy in advanced AD as compared to cholinesterase inhibitors alone, whereas another demonstrated that the combined treatment had no benefit (Howard et al., 2012).

Pharmacological Therapy for Problematic Behaviors

Behavior changes are common in the mid- to later stages of progressive dementia and although nonpharmacological interventions are preferred, supplementation with a tailored drug regimen is sometimes necessary. Psychotropic medications, primarily antipsychotics, can be administered to help the individual regain control and be less disruptive—positive outcomes for the caregiver as well as the patient. Drugs must be prescribed in the lowest effective dose for the shortest amount of time. The patient needs to be closely monitored for effectiveness and adverse side effects. Psychotropic medications have a high risk of adverse drug events and this is covered in Chapter 20, “Reducing Adverse Drug Events.”

Psychotropic therapy for different behaviors is always short term. Once the target symptoms are relieved or abbreviated, then consideration must be given to terminate therapy. Health care professionals and families are often hesitant to stop antipsychotics fearing a return or worsening of neuropsychiatric symptoms, although the literature reflects that these can generally be withdrawn without detrimental effects (Declercq et al., 2013). Long-term psychotropic drug therapy should be considered only if the symptoms reoccur. Psychotic symptoms (such as delusions and hallucinations) frequently occur in the later stages of progressive dementia and are often associated with agitation and aggression (Ropacki & Jeste, 2005). The conventional antipsychotic, haloperidol (Haldol), has been used for decades and remains the most commonly used drug for rapid tranquilization and control of psychotic symptoms in individuals with dementia. A Cochrane Review (Lonergan, Luxenberg, & Colford, 2002) validated the useful role of haldol in managing aggression but did not find evidence for its role in managing agitation for patients with dementia. The side effects of conventional antipsychotics are considerable and include extrapyramidal symptoms, tardive dyskinesia, sedation, orthostatic hypotension, and falls.

Although not FDA approved, the atypical antipsychotics are often prescribed for use in patients with dementia. Evidence indicates that they may benefit people with dementia but the risks of adverse events (cardiovascular, extrapyramidal symptoms) may outweigh the benefit, especially with long-term treatment (Maher et al., 2011). Agents available on the market include risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and paliperidone. There are little to no published data on the efficacy and safety of the last three drugs listed. Additional research is needed to determine when and how to use psychotropic medications to address behaviors in individuals with dementia. Other drug categories are sometimes used to control behavioral symptoms.

Benzodiazepines (lorazepan, oxazepan, alprazolam) are sometimes used to manage agitation and aggression; however, the risk–benefit ratio is often unsatisfactory. Although the benzodiazepines may be useful in rapidly sedating the agitated patient with dementia, the potential for falls and worsening of cognition limit long-term use. Again, nonpharmacological interventions to treat behavioral manifestations of distress are preferred.

Although antidepressants (Seitz et al., 2011) and anticonvulsants are sometimes used to treat agitation in dementia, there is insufficient evidence to support their use. Behavioral disturbances should not necessarily be interpreted as depression.

Supplemental Drugs

Anti-inflammatory drugs and estrogen; herbals, such as gingko; and vitamins, such as B₁₂, folate, and vitamin E—although sometimes touted and commonly used—have no proven efficacy for dementia although some isolated studies have demonstrated a benefit. Dementia associated with VaD requires appropriate control of hypertension, hyperlipidemia, and aspirin therapy. Parkinsonism (rigidity), seen with DLB, may benefit from dopaminergic therapy. Selective antidepressants and amphetamines may be effective in reducing the behavioral symptoms in FTD (Nardell & Tanjo, 2014).

Nonpharmacologic Interventions

Nonpharmacological strategies, including those from the cognitive, behavioral, and environmental domains, in combination with staff support and education are effective. Physical/functional, environmental, psychosocial, behavioral, and end-of-life (EOL) care interventions are discussed as follows.

Physical/Functional Interventions

Maintaining physical and functional well-being of the individual with progressive dementia facilitates independence, maintains health status, and can ease the caregiving burden. Interventions include adequate nutrition and hydration, regular exercise, maintenance of ADL, proper rest and sleep, appropriate bowel and bladder routines, proper dental hygiene and care, and current vaccinations. As comorbidities are common (Lyketsos et al., 2005) regular assessment, vigilant monitoring, and aggressive management of acute and chronic conditions are necessary. Vehicular-driving safety might need to be examined as recent evidence indicates that individuals with dementia pose a risk in driving safety (Man-Son-Hing, Marshall, Molnar, & Wilson, 2007). There is insufficient evidence to support or refute the benefit of neuropsychiatric testing or intervention strategies for drivers with dementia (Iverson et al., 2010).

Environmental Interventions

A specialized ecological model of care, which facilitates interaction between the person and environment in a more homelike atmosphere, has proven to be beneficial for individuals with dementia. This model affords greater privacy, encourages meaningful activities, and permits more choice than the traditional model of care. It also demonstrates that individuals with dementia experience less decline in ADL and are more engaged with the environment with no measurable differences found in cognitive measures, depression, or social withdrawal (Reimer, Slaughter, Donaldson, Currie, & Eliasziw, 2004). A study examining social engagement of residents before and after conversion to a household model (culture change) was highly significant (Morgan-Brown, Newton, & Ormerod, 2013).

A systematic review reported inclusive results and suggested that more research is needed with regard to the use of bright light in fostering better sleep and reducing behavior problems in dementia (Forbes et al., 2009). The use of aromatherapy to reduce disturbed behavior, promote sleep, and stimulate motivation also shows promise but needs more study (Thorgrimsen, Spector, Wiles, & Orrell, 2003). Manipulation of the environment (alarms, circular hallways, visual, or structural barriers) to minimize wandering has not been conclusively demonstrated to be effective (Futrell & Melillo, 2002). There is a lack of robust evidence supporting nonpharmacological interventions for wandering (Robinson et al., 2007).

Psychosocial Interventions

Mental and social engagement is important to the well-being of all older adults. Meaningful activity and involvement are no less important in individuals with dementia. Although the effectiveness of counseling or procedural memory stimulation is not supported in mild-stage dementia, reality orientation does appear to be effective (Bates, Boote, & Beverley, 2004). The evidence suggests that cognitive therapy is more beneficial than no therapy at all but it may be patient specific (Carrion, Aymerich, Bailles, & Lopez-Bermejo, 2013; Woods, Aguirre, Spector, & Orrell, 2012). Validation therapy, based on caregiver acceptance of the reality of the person with dementia’s experience, may be of value but the evidence is lacking (Neal & Barton Wright, 2003).

Recreational therapies, including music, have been shown to reduce psychological symptoms in dementia with limited efficacy and questionable duration of action (O’Connor, Ames, Gardner, & King, 2009) and more research is needed to explore the effects of music therapy on the behavior and well-being of individuals with dementia (Wall & Duffy, 2010). A growing body of evidence shows that individuals with dementia enjoy music but there is little scientific investigation within this area (Baird & Samson, 2015; Samson, Clement, Narme, Schiaratura, & Ehrle, 2015). In addition to music, other cultural arts (poetry, storytelling, dance) have reflected positive social and behavioral changes though there are some study design issues that limit inclusion in a systematic review (de Medeiros & Basting, 2014). Structured nonpharmacological short-term occupational therapy interventions were more useful in improving apathy in patients with dementia than activities of the patient’s choice (Ferrero-Arias et al., 2011).

Support groups, counseling, and education for individuals with early AD and their caregivers are essential. Caregivers often experience physical, financial, social, and emotional losses and providing information through a structured education program and engaging them in the care-planning process is essential (Battaglini, 2013). Areas for caregiver education are detailed in Table 16.2.

Behavioral Interventions

Behavioral and psychosocial symptoms of dementia are common with every form of progressive dementia, particularly in the moderate stage. The three most troublesome symptoms are agitation, aggression, and wandering. Problematic behaviors that occur during meals or bathing can be particularly challenging. It is important to recognize and realize that any new behavior could be a sign of an acute illness or an environmental influence. Unrecognized pain can cause disruptive behavior. The Progressively Lowered Stress Threshold (PLST) is a framework to optimize function, minimize disruption, and help the caregiver (M. Smith, Hall, Gerdner, & Buckwalter, 2006). The PLST model increases the positive appraisal and decreases the negative appraisal of the caregiving situation (Stolley, Reed, & Buckwalter, 2002) and helps the caregiver manage the aggressive behaviors demonstrated in AD (Cheung, Chien, & Lai, 2011; Lindsey & Buckwalter, 2009). By adapting the environment and routines, interventions are designed to help the patient with dementia use his or her functional skills and minimize potentially triggering reactions. There are six essential principles of care in the PLST:

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