Evidence-Based Interventions to Improve Quality of Life in Dementia

Rebecca G. Logsdon, PhD

Research FundingNational Institute on Aging AG13757, AG10845, AG05136, and AG14777

Alzheimer’s Association FSA-95-009, IIRG-0306319Administration on Aging Alzheimer’s Disease Grants to

States

Northwest Research Group on AgingLinda Teri, Rebecca Logsdon, Sue McCurry,

Kenneth Pike, David LaFazia, Amy Moore, June van Leynseele

Cathy Blackburn, Cat Olcott

Quality of LifeQuality of life for older adults with chronic illness: a sense of well-being, satisfaction with life, and self-esteem, accomplished through the care received, the accomplishment of desired goals, and the ability to exercise a satisfactory degree of control over one’s life.

Quality of Life for Individuals with Dementia

Sense of well-being Absence of clinical depression and excessive anxiety Freedom from physical pain Safety and security

Satisfaction with life Preferred living arrangements Engagement in meaningful and pleasant activities Participation in family and social activities

Self-esteem Recognition of contributions Respect from others

Quality of Life for Individuals with Dementia

Sense of well-being Absence of clinical depression and excessive anxiety Freedom from physical pain Safety and security

Satisfaction with life Preferred living arrangements Engagement in meaningful and pleasant activities Participation in family and social activities

Self-esteem Recognition of contributions Respect from others

Quality of Life for Individuals with Dementia

Sense of well-being Absence of clinical depression and excessive anxiety Freedom from physical pain Safety and security

Satisfaction with life Preferred living arrangements Engagement in meaningful and pleasant activities Participation in family and social activities

Self-esteem Recognition of contributions Respect from others

Quality of Life Care received

Appropriate level of assistance Provided in ways acceptable to the care recipient

Achievement of desired goals Recognition of personal preferences Individualized care to accomplish individualized needs

Control over one’s life Participation in decision-making Freedom to choose from acceptable alternatives

Quality of Life Care received

Appropriate level of assistance Provided in ways acceptable to the care recipient

Achievement of desired goals Recognition of personal preferences Individualized care to accomplish individualized needs

Control over one’s life Participation in decision-making Freedom to choose from acceptable alternatives

Quality of Life Care received

Appropriate level of assistance Provided in ways acceptable to the care recipient

Achievement of desired goals Recognition of personal preferences Individualized care to accomplish individualized needs

Control over one’s life Participation in decision-making Freedom to choose from acceptable alternatives

QOL & Psychosocial Intervention: RCT Evidence Base Maximize social and ADL function

Dooley, 2004; Gitlin, 2001, 03, 05; Graff, 2006; Lowenstein, 2004 Spector, 2003; Tarraga, 2006

Treat depressive symptoms and encourage pleasant activitiesTeri, 1997, 2005; Gerdner, 1996, 2002; Huang, 2003 Lichtenberg, 2006; Logsdon, 2006

Improve or maintain physical mobilityLazowski, 1999; Littbrand, 2006; Rolland, 2007 (NH) Teri, 2003; Logsdon, 2005

Reduce caregiver burden and depressionGallagher-Thompson, 1994, 2000, 07; Schulz, 2003, 05 Mittelman, 1995, 2004; Teri, 2005

RDAD: Reducing Disability in Alzheimer’s Disease

Teri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner D, Barlow W, Kukull W, LaCroix A, McCormick W, Larson E. (2003) Exercise plus behavior management in patients with Alzheimer’s disease: A controlled clinical trial. JAMA, 290(15); 2015-2022.

Funded by the National Institute on Aging AG10845 and AG14777

Active treatment:● Home-based exercise – strength, balance, endurance ● Behavior therapy – communication, problem-solving Control:● Routine Medical Care Therapists: Master’s level home health providers (SW & PT) 12-week treatment duration, monthly follow-up 4 months MMSE 0 to 29; Mean = 17 Assessments at baseline, 3, 6, 12, and 24 months

Benefits of Physical Activityfor Individuals with Dementia

Improves Strength and Mobility

Lazowski, et al, 1999 Arkin, et al, 2003 Hageman, et al, 2002 Rolland, et al, 2000

Reduces Depression Teri, et al, 2004

Decreases Behavioral Disturbances

Rolland, et al, 2000 Teri, et al, 2004

May Mitigate Cognitive Decline

Rolland, et al, 2000 Emery, et al, 1998, 2003

Challenges of Exercise for Individuals with Dementia

• Reluctance to try new activities

• Difficulty learning & remembering to do exercises

• Inability to exercise independently due to safety concerns

• Family caregivers lack knowledge about exercise, already burdened by daily tasks, may be physically frail

RDAD Treatment Protocol• 12-week program• Delivered by community home health

providers (physical therapist or social worker)• Exercise

Aerobic/endurance activities (walking) Strength Balance Flexibility

• Problem-solving Education about AD Intervening with behavioral problems Enhance caregiver resources and skills

Change in Percent of Subjects Exercising 60+ Minutes a Week

3-Month 12-Month0

5

10

15

20

25

30

26

86

3

RDADRMC

ITT: Pre-Post <.01

Community-residing AD patientsMean Age = 78Mean MMSE = 1756% exercising 60+ minutes at baseline

3-month 12-month-20

-15

-10

-5

0

5

10

1510

8

-17

-6

RDADRMC

RDAD OutcomesSF-36 Role FunctioningITT: Pre-Post p < .01

3-Month 24-Month-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

0.5

1

-2

-3.2

0.600000000000001

-1.6

RDADRMC

HDRS, Pts >6 on Cornell at baselineITT: Pre-Post p < .05Longitudinal p = .05

Change in Behavior

Illness or Cognitive Decline

Increased ADL Im-pairment

Behavioral Problems

-10%

0%

10%

20%

30%

40%

50%

60%

19%24%

19%18%

27%

50%RDADRMC

Reasons for residential placement over 24-month follow-up

STAR-C: Caregiver SupportTeri L, McCurry SM, Logsdon RG, & Gibbons LE. (2005). Training community consultants to help family members improve dementia care: A randomized controlled trial. The Gerontologist, 45(6), 802-811.

Funding: Alzheimer’s Association Pioneer Grant P10-1800

Active treatment:● Seattle Protocols – communication, problem solving, pleasant events Control:● Routine medical care Caregiving consultants: Master’s-level mental health counselors 8 weekly sessions, monthly phone calls 4 months MMSE 0-28; Mean = 14 Assessments at baseline, 3, 6, and 12 months

STAR Caregivers• 8 weekly in-home caregiver counseling sessions• Communication, problem-solving, pleasant events• Target behaviors

• agitation, anxiety, depression• Provided by master’s level caregiving consultants• Companion for person with dementia if needed• Training, ongoing supervision, and weekly monitoring of

adherence to protocol by geropsychologists

ABCs and Problem-Solving Problem behaviors can interfere with your ability to

care for a person with dementia and their ability to enjoy life

Understanding dementia-related behaviors requires observation of the ABCs: Activators, Behaviors, and Consequences

You can change a problem behavior by preventing it, or stopping it once it occurs

gram.

The ABC Problem Solving Plan

Where can you break the chain of

events???

Promoting Pleasant Events Individuals with dementia retain many skills

despite cognitive impairments. Interpersonal relationships are very

important, and are fostered by shared pleasant activities.

Caregiver depression and burden may be lessened by focusing on positive, rather than negative interactions.

Identify and Re-introduce Pleasant Activities

What did the person enjoy in the past?

What does he/she enjoy now?

How can tasks be modified to accommodate current abilities?

Who is available to help with these activities?

CESD

STAR-C Outcomes

STAR RMC10

11

12

13

14

15

16

17

14.8

13.212.4

13.6

12.5

15.8

STAR RMC15

17

19

21

23

25

2725

23

20

23

21

26Burden Pre-Post p<.01

Longitudinal p<.03

STAR RMC2021222324252627282930

28.1

25

22.323.3

RMBPC-Reaction Pre-Post p<.03Longitudinal p<.04

STAR RMC25

25.526

26.527

27.528

28.529

29.530

27.828.3

29.4

28.428.4 28.2

QOL-AD Pre-Post p<.05Longitudinal p<.03

BaselinePost-TreatmentFollow up

Pre-Post p<.05Longitudinal p<.02

Early Stage Support GroupsLogsdon RG, McCurry SM, & Teri L (2005). Time limited support groups for individuals with early stage dementia and their care partners. Clinical Gerontologist, 30(2), 5-19.

Funding: Alzheimer’s Association; R Logsdon, PI

Active treatment:● Early Stage Memory Loss seminar program Control:● Delayed treatment Support Group Facilitators: Master’s level social workers 9 weekly sessions, participant and care partner attend together MMSE 18-30; Mean = 24 Assessments at baseline and post treatment (2 months)

Early Stage Memory Loss Seminars

Groups planned and run by the Alzheimer’s

Association Chapter

Individuals with early stage dementia and care

partners attend together

Didactic Content: Everyone together, speaker or

facilitator-led information

Discussion, Questions, Support: Participants and

Care partners split up into two groups

Early Stage Memory Loss OutcomesFor the Person with Memory Loss

Improved Social Functioning (p < .05) Decreased Family Conflict (p < .05) Decreased Depression (p < .01) Improved Quality of Life (p < .01)

For the Care Partner Decreased Distress about Problem Behaviors (p<.05)

Benefits of Early Stage Groups

Social Support

Information About AD

Decreased Isolation

Emotional Support

Legal Information

Community Resources

Caregiving Advice

0% 5% 10% 15% 20% 25% 30% 35%

Care Partner Participant

Logsdon, et al, 2005 (Clinical Gerontologist)

Take Home Messages from Research Quality of life as perceived by the person with dementia does

not necessarily decline due to memory loss or cognitive decline.

Quality of life is strongly influenced by mood. Mood is influenced by pleasant activities, exercise, and social

support. Family members, friends, and other caregivers can

significantly impact QOL for individuals with dementia. What’s good for the person with dementia is good for the

caregiver.

AoA Sponsored Evidence-Based Translation of These InterventionsRDAD Ohio: Community-based

investigation Washington State:

Memory Care & Wellness Program in Adult Day Centers

STAR-C New Mexico Oregon

Technical Support: Manuals, Materials, Measures

Training: For Planners, Evaluators, & Direct Care Providers

Fidelity Monitoring: Ongoing Supervision, Consultation