Dementia (Biopsychosocial model (Spector and Orrell (2010) dementia is…
Spector and Orrell (2010) dementia is interrelationship of = NF (neurological factors) + MS (mental stimulation) + SP (social psychology) + P (personality) + SS (sensory stimulation) + E (environment) + PH (physical health) + LE (life events) + M (mood)
- fixed and tractable factors that affect dementia, with a timeline for stages, and potential for psychosocial and biological interventions
- Brody et al. (1971) people with dementia experience disability above that arising purely from nuero impairment
- Butler & Lewis (1982) loss of perceptual ability --> disorganised thinking, depression, delusions and hallucinations
Mental stimulation: (arguably most important factor)
- "Work of any kind, even mental work alone, is a means of preventing precocious senility” (Lorand, 1913)
- ‘Use it or lose it’ (Swaab, 1991): Mental activity can lead to new learning and increased cognitive functioning in dementia. Can lead to new neuronal pathways being formed --> stimulation
and activity reduces decline (Orrell et al, 2014).
Social psychology: the way people are treated and spoken to by others has an impact on how they feel and behave
- Kitwood's (1997) 'Malignant social psychology) 17 common factors which can actually exacerbate dementia: disempowerment, infantilisation, outpacing, ignoring. e.g. feeding the patient even though they can still feed themselves just because it is quicker, putting people in wheelchairs when they can still walk, changing tone of voice/speaking style, and talking over people with dementia
- +ve person work includes recognition, negotiation, choice, etc.
- Zimmerman et al. (2005) QoL for 421 patients in care setting --> change in QoL dependent on specialist worker approach used, staff training and activity participation. SS also identified as important.
- High incidence of impairment in vision, hearing and taste in older people. For people with dementia, effects are likely to be exaggerated, due to inattention or difficulty in selecting appropriate information.
- Care settings often provide little sensory input --> Hebb (1953) even ‘normal people’ placed in sensory isolation can experience hallucinations
- Goddaer and Abraham (1994) showed a 63.4% reduction in agitation during mealtimes when relaxing music was played, in people with moderate-severe dementia.
- Haughie et al. (1992) evaluated the impact of a visitor with a trained dog in a psychiatric hospital ward where most patients had a diagnosis of dementia. Interaction levels increased markedly when the dog and visitor were present, and a number of aspects of the participants’ behaviour, including mobility and dependency, were rated by nurses as improved when the dog was present.
- Heyn et al. (2004) meta-analysis, effects of exercise training in people with dementia --> positive changes in fitness and cognitive function
- Livingston et al. (2005) systematic review - stimulation approaches (e.g. music and multisensory stimulation) have useful immediate effect but evidence is lacking for longer term effects.
- Woods and Clare (2008) - argued that “too much” stimulation is unhelpful for people with dementia- aim to avoid stimulus overload, with many care environments being too noisy/have too much happening around the person which can increase confusion --> the stimulation must be enjoyable
Personality: e.g. coping mechanisms, sense of humour, intelligence.
- Low et al. (2002) higher neuroticism predictive of delusions and overall behavioural disturbance (symptoms of dementia) – but small sample and inconsistent with previous findings
- DeRonchi et al. (1998) links between low education and dementia irrespective of other factors (e.g. gender and occupation).
- Katzman (1993) suggests education increases synaptic density, leading to delay in symptoms of Alzheimer’s disease by around 5 years
- Bahro et al. (1995) coping strategies and adaptive mechanisms of people with dementia include denial, externalization, somatization and self-balme --> could be indicative of behaviour e.g. externalization may lead to interpersonal difficulties which may be hard to resolve because of communication problems
Environment: presence of memory aids and supports e.g. signposts, door markings, reminders.
Physical Health: medication may impact on mood and increase confusion, pain may impact on symptoms of dementia.
- Certain physical health conditions e.g. heart disease and high blood pressure are linked to Vascular dementia - Gorelick (2004)
- Laurin et al. (2001) compared to no exercise, physical activity was associated with lower risk of cognitive impairment, dementia and specifically AD.
- Physical health problems and falls --> limit a person’s ability to attend day care/other activities --> reduced stimulation and further decline.
Life events: dramatic life events such as loss of important other(s) or move into care can trigger dementia or exacerbate symptoms.
- Orrell and Bebbington (1998) Life events increase risk of admission into hospital for people with dementia = leads to deterioration
- Pharmacological interventions (e.g. cholinesterase inhibitors for Alzheimer’s, aspirin for vascular dementia) might impact on cognitive function/mood, which can have knock-on effects in other areas such as reaction to life events.
Mood: overlap between depression/anxiety and dementia
- Ballard et al. (1996) approx 20% clinical samples containing people suffering from both
- Clinical depression could present as pseudodementia where person’s memory appears affected because they are inattentive to their surroundings/unable to retain new info due to low mood
- Predicts stages of disease progression and inevitable deterioration --> can be used to rationalize treatment strategies e.g. institutionalization appropriate in later stages
- Disease stages provide structure in peoples understanding of what is happening, making it more predictable = allows to make plans for the future
- Some overlap between fixed factors e.g. sensory deficits and sensory impairments
- Makes assumption that people with dementia are aging, so would not fit well with younger people with dementia
- Not tested empirically
Reality orientation (Folsom, 1966):
- Presentation and repetition of time, place and person related info
- Important impact in 1960s: one of 1st non-drug
interventions for dementia
- 24 hour RO (used in every interaction) versus classroom /group RO. Might use maps, categorising words /objects, food, current affairs.
- RO boards: contain info such as day, date, next meal, weather, news headline, name of home, daily activities.
- Spector et al. (2000) RO associated with sig. improvements in both cognition and behaviour --> but also need large, well-designed must-centre trials to develop a programme of evidence-based therapy focused on cognitive stimulation
- Spector et al. (2001) Piloted in 3 care homes and one day centre- improvements in cognition and depression for p’s compared with control group
- Despite their longevity, their effects remain open to question and many studies have been either small, of poor methodological quality, or both (Orrell & Woods, 1996).
- Woods and Clare (2004): It includes two main aspects: 1) 24-hour RO, with changes to the environment (clear signposting of locations around the ward or home, extensive use of notices and other memory aids, and consistent staff behaviour) 2) small, structured group sessions, meeting regularly, often several times a week for half an hour or so.
Reminiscence Therapy (RT, Butler and Lewis, 1977):
- Individual/group work involving reflection on the past, using prompts e.g. music, pictures
- Focus on LTM, the last to deteriorate in dementia. Popular: avoids failure experiences, aids communication.
- Woods et al (2005) limited evidence but positive indications of changes in cognition and mood. Woods et al. (2012) showed that reminiscence groups for PwD and their carer led to no significant differences in primary outcome (QoL), increased carer anxiety and increased costs.
- Brooker and Duce (2000) higher levels of wellbeing during reminiscence groups, compared with other activities and unstructured time in people with dementia attending three day hospitals
- a lack of clarity regarding the specific aims but promising development is the involvement of family caregivers in reminiscence work with the person with dementia (Gibson, 2004)
- Woods and Clare (2008): suitable for people with mild-moderate degree of dementia, particularly in a group setting. Important to be aware of p's life histories, in case events that have traumatic meanings for some p's are being raised by others, and there need to avoid intrusive approach
- Stimulating the senses through sound, taste, touch, smell and visual images
- Snoezelen rooms: calming music, visual stimulation from fibre optics and lava lamps, aromatherapy, etc
- Some evidence-base, e.g. Baker et al (2001): associated with improvement in mood and reduced behavioural disturbance. Also argued that too much stimulation is unhelpful / distressing
- Can be incorporated into other techniques
Cognitive Behavioural Therapy (CBT):
- Initially seems counterintuitive to think that it can be used as it involves utilising cognitive skills which are thought to be lacking in those with dementia, but feasible and effective (probably best for mild-moderate)
- Spector et al. (2014) pilot RCT with 10 sessions of CBT for anxiety in dementia --> sig. reductions in both anxiety and depression which maintained up to 6m later --> sessions included identifying/practicing strategies for feeling safe, ‘realistic negative automatic thoughts’, calming thoughts and behavioural experiments and supported by family carer outside CBT sessions.
- Scholey and Woods (2003) case series, 7p with mild dementia --> sig. overall improvements following 8 sessions of CBT. Helped with feelings of insecurity, loss of control, hopelessness and interpersonal issues
Cognitive Stimulation Therapy (CST):
- Aim: to improve cognitive function by providing mental stimulation through various means, including; implicit learning, making new semantic connections, use of opinion above factual knowledge, multi-sensory learning, reminiscence to aid orientation, consistency and continuity between sessions.
- Largely based on RO work, involving group intervention of 14 sessions or more. Also annualised, so can be delivered by a range of health professionals. Includes themed activities e.g. word association, categorisation, current affairs, food, faces
- Spector et al. (2003) evaluated as a RCT with 201 dementia p's in 23 centres: CST = sig. improvements in cognition and quality of life (no behaviour change) and cognitive benefits were comparable to anti-dementia drugs, and it is cost-effective
- NICE guidelines (NICE, 2006) recommend group Cognitive Stimulation to all people with mild-moderate dementia, regardless of medication being used.
- Improvements in QoL mediated by the improvements in cognition (Woods et al., 2006)
- RCT combining CST with medications are now appearing --> Onder et al. (2005) showed improved cognitive function with a home-based stimulation programme involving the family caregiver
- Orrell et al (2014) shown that 24 further, weekly sessions can lead to significant improvements in QoL for up to 6 months
- Orgeta et al (2015) has looked at ‘Individualised CST (iCST): 75 sessions delivered by family carers over 25 weeks = sig. improvements in carer QoL and relationship between person and carer. Primary outcomes (cognition and QoL in person with dementia) did not improve
- Important aspects = individualised, person-centred, carers are considered, learning is possible, realistic expectations
- BPS model used: PS interventions (e.g. cognitive rehabilitation and cognitive stimulation) as focus = improve mood, QoL and social psych. Biological interventions include physical exercise and medication
What is it
- Original conceptualisation = mental handicap/form of madness
- An illness of the brain, with neurological basis (Alzheimer, 1908) --> encouraged to be more socially accepted as an illness
- DSM-IV: multiple cognitive deficits including memory impairment (impaired ability to learn new/previously recalled info), and one or more of, aphasia (people and objects), apraxia (motor activities), agnosia (recognise objects), or disturbances in executive functioning (planning, organising etc.) --> don't really have a problem at recalling childhood events
- DSM-V: Dementia replaced by ‘Major / Mild Neurocognitive Disorder’ (NCD). Mild NCD is a new disorder (previously / otherwise known as Mild Cognitive Impairment / MCI). MCI was not part of DSM-IV --> allows diagnosis of less disabling syndromes that may still be focus of concern. Major or mild vascular NCD and major or mild NCD due to Alzheimer’s disease have been retained, whereas new separate criteria are now presented for major or mild NCD due to frontotemporal NCD, Lewy bodies, traumatic brain injury, etc.
Dementia is an umbrella term describing no. of conditions:
- Alzheimer’s: approx 2/3 of cases --> Cerebral atrophy, neurofibrillary plaques and tangles.
- Vascular dementia next most common type --> Caused by loss of blood supply to parts of brain, often through series of mini strokes -> cell death.
- Other less common types, e.g. Frontal temporal dementia, Lewy body dementia, Creutzfeld Jacob disease.
- Often difficult to diagnose dementia subtype.
Prevalence: Alzheimer's Disease International (2012)
- 65-69: 1,4%
- 70-74: 2.8%
- 75-79: 5.6%
- 80-84: 11.1%
- 85+: 23.6%
Medical model of dementia predominantly still used in assessment, formulation and treatment
- Assumes dementia is caused by organic factors (progressive deterioration of those parts of the brain that control cognitive and behavioural functioning), treated and managed according to medical authority
- Pros: can aid communication between professionals and can sometimes be more acceptable to people with dementia and families. Also, countered the assumption that mental decline is an inevitable consequence of old age.
- Cons: limitations in dementia medication (anti-cholinesterase inhibitors). symptoms may be misattributed to ‘the dementia’ without consideration of the individual, over-use of medication (especially anti-psychotics), different types of dementia defined by different pathologies.
- Relationship between changes in the brain and dementia is unclear, cases of advanced dementia with limited neurological damage at post-mortem, cases of substantial neurological damage with no accompanying dementia symptoms, and a degree of cerebral atrophy found in healthy older people (Burns et al, 1991)
Dialectical model (Kitwood, 1993)
- Dementia is an interrelationship between neurological damage and psychological factors
- Dementia = personality + biography + health + neurological impairment + social psychology.
- Used this model to emphasise the importance of ‘personhood’ and person-centred care, which has had great impact on how dementia is viewed
= Don't treat someone as part of a diagnosis, treat them as an individual
- Nygren et al. (2005) resilience, sense of coherence, life purpose and self-transcendence = aspects of inner strength that are crucial for retaining health when ageing