Nonpharmacological Interventions for Use in Dementia
Michele M. Grigaitis, MS, FNP, BC
Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
In the United States, people 65 years of age and older are the largest growing segment of the population, and aging is the primary risk factor for developing the most prevalent dementia, AD. Progressive dementias are terminal illnesses; people with AD or a related dementia may live as long as 20 years before succumbing to related complications. Although the pathological processes of dementia cannot yet be halted or reversed, caregivers can manage symptoms and improve the quality of life for people with the disease.
Key Words: Alzheimer's disease, dementia
Abbreviations used: AD, Alzheimer's disease
Health care providers can expect to encounter an increasing number of older adults with cognitive impairment and the accompanying behavioral symptoms. The American Alzheimer's Association estimates that about 4.5 million individuals currently suffer from AD, the most common cause of dementia in the United States. As the population in the United States grows older, the prevalence of AD is expected to increase to 16 million by the middle of the 21st century. Rates among institutionalized older people are high. Almost half of the residents in nursing homes have dementia, and recent evidence suggests that rates in assisted-living facilities exceed 60%. Of equal importance, 83% of older adults with a cognitive disorder also experience behavioral symptoms.
This article describes behaviors associated with dementia and nonpharmacologic interventions that consider a person's environment, personality, and potential unmet needs. Strategies that can be used by both patients and caregivers are presented. Although this article focuses on nonpharmacological interventions, attention must be paid to pharmacotherapies. Appropriate medications are examined elsewhere in this issue.
Continuum of Cognitive Impairment
Cognition refers to the ability to execute complex mental processes such as learning, perceiving, making decisions, and remembering. Cognitive impairment exists on a continuum, from mild cognitive impairment to dementia. Differentiation is based on the number, type, and severity of deficits in mental capacity that a person exhibits. Mild cognitive impairment causes significant and persistent memory deficits, yet people remain functional and independent in most ways, without other clinical signs of dementia. Each year, however, the cognitive deficit progresses to AD in as many as 12 to 15% of the people with mild cognitive impairment.
Dementia refers to a global loss of cognitive and intellectual functioning caused by damage to the brain severe enough to interfere with social and occupational performance. Dementia is a general clinical term that refers to a group of disorders with common symptoms but different causes. The etiology of dementia varies and may be related to conditions such as Parkinson's disease, Huntington's disease, acquired immune deficiency syndrome, or one or more of the neurodegenerative disorders discussed elsewhere in this issue.
Delirium, depression, and adverse effects of medication also can trigger dementia-like syndromes, which can overlap with existing dementia or appear independently. Behavioral symptoms caused by these and other health conditions may be reversed or arrested. Comprehensive assessment of all possible causes of symptoms of cognitive impairment is therefore essential.
Declines in cognition, activities of daily living, and behavior, considered the three symptomatic domains of AD, create challenges for caregivers. Subtle common cognitive symptoms usually appear first. The functional losses that follow are likewise subtle but eventually lead to complete dependence. Multiple behavioral symptoms, which are often the most distressing for caregivers, become more prominent as the disease progresses. These three domains do not exist separately; instead, they overlap and influence one another. Cognitive deficits facilitate functional disability. In turn, both contribute to the development of behavioral symptoms. Nonpharmacologic interventions must address the following three issues: cognitive impairment, challenging behaviors, and activities of daily living.
Cognitive deficits associated with dementia affect several higher cerebral functions, including memory impairment, aphasia, apraxia, and agnosia. Short-term memory loss is a common presentation in the practitioner's office. The patient, family, or both describe difficulty recalling recent events as well as difficulty learning new material. Attention deficits are present early in the dementing process.
Strategies include minimization of stimuli, which helps increase patients' attention span by decreasing their distractibility. Early in the disease process, the use of central information areas is helpful. These areas consist of calendars, notes, or message boards placed on a refrigerator or on a wall near the phone. The use of visual cues can be effective. For example, if a patient uses a basket to hold keys and glasses, affixing a picture of glasses and keys to the side serves as a cue to the contents of the basket. Caregivers are encouraged to give patients simple directions. Breaking complex tasks into smaller steps allows patients to complete a task with minimal redirection. In all stages of the dementing process, maintaining a consistent structured routine is helpful and is encouraged.
Aphasia is the inability to use symbols to communicate. Expressive aphasia is the decreased ability to form words to express oneself clearly orally or in writing. Receptive aphasia is the decreased ability to understand spoken or written language. Common in AD is word-finding difficulty; that is, difficulty in the ability to retrieve and express a thought, particularly nouns. Frequently noted is the use of circumlocution, which is the description of a noun in the absence of the word itself.