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22 Interventions in Alzheimer’s Disease KCE Reports 111 Simulated presence therapy SimPres is a technique in which a family member, or established caregiver, makes an audiotape about positive events in the life of the individual with dementia that is played to simulate their presence. It is a patented intervention of SimPres Inc., Boston, Massachusetts, US Music therapy Listening (individualized music), singing or musical activity Activity therapy Exercise therapy ADL rehabilitative care / ergotherapy (by altering activity of neurotransmitters): 34 some temporary improvements but too limited data (small studies) to allow definite conclusions 1 Cochrane review on acupunture for vascular dementia: 35 no RCTs, no conclusion. NICE-SCIE: 2 RCTs showing aromatherapy reduced agitation and BPSD in severe dementia. 1 However, both studies had been excluded by SBU. DIMDI: 1 negative study on therapeutic touch; 1 negative study on progressive muscle relaxation 28 Livingston: 1 RCT, low level of evidence 5 Livingston: 6 Studies (4 also presented in Cochrane), moderate level of evidence, but not lasting 5 Sung: 0 Studies on agitation and preferred music 36 1 Cochrane review (2004) including 5 RCTs but all concerned different types of interventions; only 2 studies accepted by SBU showing reduced agitation and increased wellbeing during the intervention. SBU included another 3 RCTs showing the same results; however 2 were excluded in Cochrane 21 NICE-SCIE: 1 RCT, no effect on behaviour. 1 Structured activity interventions, including Physical activity Structured activity consisting of sporting activities or games used to stimulate cognitive and psychosocial functions. Livingston: 5 studies, all different interventions, inconsistent results and low level of evidence 5 Exercise, movement, walking as Livingston: 2 studies, low level of evidence an intervention for neuropsychiatric symptoms. 5 SBU: 1 meta-analysis and 5 studies (of which one excluded by Cochrane): some significant positive outcomes (physical fitness and mood in one RCT, cognition, and behavior in another RCT) but no scientific evidence: studies used different inputs and outputs; many drop-outs 21 Cochrane review: 2 studies (not included by SBU) and 1 meta-analysis: insufficient evidence and many differences in study parameters between studies 37 Functional performance interventions Eating, dressing, bathing. SBU: one study “dressing” intervention: positive effect on participation and behavioral problems during ADL; caregiver time doubled 21 SBU: one study on nutritional supplements and staff teaching on nutrition: increased weight but not improved cognitive function or ADL; one study on informal caregiver instruction about
KCE Reports 111 Interventions in Alzheimer’s Disease 23 SBU: 6 studies on communicatio n, interaction and relationship interventions 21 Milieu therapy category I nutrition and behavioral (eating-related) interventions, no significant weight gain after one year 21 Watson et al 38 : systematic review on interventions for feeding difficulties: one RCT (not accepted by SBU) and 12 non-randomised studies: not enough good quality studies to conclude and more research needed. DIMDI: 5 studies on ergotherapy, no differences vs usual care in two studies 28 The studies by Gitlin et al. 39-41 are grouped under caregiver support by other authors. The study by Graff et al. reports improvement for ADL performance as 42, 43 well as for caregiver’s sense of competence. Communication, interaction and relationship interventions Various designs and outcome measures. The shaping of the material environment, eg collective living unit versus classic nursing home, wandering areas, bright light therapy during meals or daytime to re-establish circadian rhythms Category II Broad, care program interventions, includes sensory stimulation (see also above). Category III ‘gentle’ subjective barriers to obscure the exit or to avoid agited patients will wander (see also paragraph 3.2.2.2 on behavioral problems) Environmental manipulation Various positive effects. As effects were not confirmed in a second trial, SBU concluded that no evidence could be stated. 21 Livingston: Low level of evidence for group living (1 study). 5 1 Cochrane review and 1 study for bright light: no evidence as only 1 study 21 NICE-SCIE: 5 RCTs on light therapy, no effect on behaviour. 1 Livingston: Low level of evidence for special care “dementia units” (6 controlled non- randomized studies (none included by SBU), conflicting results) SBU: 1 controlled study of “intensive” care program interventions: progression of dementia not delayed - 2 controlled studies on Special dementia care units: one positive outcomes and less health care use, one no clear outcomes, no scientific evidence. One controlled study (12 months, N=54, Controls=44) on day care vs. classical home care: less stress in caregivers, delayed institutionalisation 21 Livingston: Weak level of evidence for changing the environment to obscure the exit (consistent evidence of 9 small non-randomised studies) 5 Low level of evidence for mirrors, signposting, unlocking doors (all non randomized studies). 5 In conclusion, for the therapies described and discussed above, insufficient high quality evidence is available to support or reject reality orientation, self-maintenance therapy, individualized special instruction or validation therapy. The results for reminiscence therapy are positive (4 studies) according to the Cochrane authors, but need to be confirmed because of the variation in types of reminiscence exercises and the limited number and relative low quality of studies. However, in the SBU study only one RCT of these 4 RCTs is retained, mainly because of inclusion criteria for dementia. This study showed no improvement.
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KCE reports 33 Effects and costs of
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