Research in Gerontological Nursing

State of the Science Commentary 

Nonpharmacological Strategies for Patients With Early-Stage Dementia or Mild Cognitive Impairment: A 10-Year Update

Joel G. Anderson, PhD, CHTP; Ruth Palan Lopez, PhD, RN, GNP-BC, FGSA, FAAN; Karen M. Rose, PhD, RN, FGSA, FAAN; Janet K. Specht, PhD, RN, FGSA, FAAN

Abstract

As the incidence and prevalence of early-stage Alzheimer's disease and mild cognitive impairment increases worldwide, gerontological researchers continue to examine the efficacy and effectiveness of strategies to help patients and caregivers live with the disease. Although pharmacological treatments remain the focus of much of the research, nonpharmacological strategies and approaches to care continue to gain ground as effective means of improving the health-related quality of life for this patient population. The current commentary summarizes the state of the science based on a series of integrative and systematic reviews undertaken by the International Dementia Scholars Collaborative as a 10-year update to a previous white paper. Selected topics from this previous white paper (e.g., support groups, nutrition, exercise, cognitive training, falls) as well as new topics (e.g., mind–body, advance care planning, driving safety) are discussed, and recommendations for future research are provided.

[Res Gerontol Nurs. 2017; 10(1):5–11.]

Abstract

As the incidence and prevalence of early-stage Alzheimer's disease and mild cognitive impairment increases worldwide, gerontological researchers continue to examine the efficacy and effectiveness of strategies to help patients and caregivers live with the disease. Although pharmacological treatments remain the focus of much of the research, nonpharmacological strategies and approaches to care continue to gain ground as effective means of improving the health-related quality of life for this patient population. The current commentary summarizes the state of the science based on a series of integrative and systematic reviews undertaken by the International Dementia Scholars Collaborative as a 10-year update to a previous white paper. Selected topics from this previous white paper (e.g., support groups, nutrition, exercise, cognitive training, falls) as well as new topics (e.g., mind–body, advance care planning, driving safety) are discussed, and recommendations for future research are provided.

[Res Gerontol Nurs. 2017; 10(1):5–11.]

There is no doubt that a breakthrough to prevent, slow, or cure Alzheimer's disease (AD) and other dementias is desperately needed. According to a recent report by the Alzheimer's Association (2016), 5.4 million individuals in the United States currently have AD, with 16 million expected to have the disease by 2050. It is the sixth leading cause of death of all adults, and the only disease among the top 10 causes of death with no prevention or cure (Alzheimer's Association, 2016). Mortality resulting from AD is increasing while death rates from cancer and heart diseases are decreasing. The health care costs to the nation, $236 billion in 2016 (Alzheimer's Association, 2016), as well as the financial and emotional toll on families, are tremendous.

Although drugs to treat cognitive symptoms of dementia may provide statistically significant improvements, the benefits are often underrated by clinicians, patients, and caregivers because the drugs fail to deliver observable and meaningful improvements (Rountree, Atri, Lopez, & Doody, 2013). Therefore, owing to a low cost, low risk of side effects, and usefulness in treating an array of symptoms, effective nonpharmacological interventions and strategies are particularly attractive for individuals with dementia. In addition, nonpharmacological interventions and approaches to care can be adapted and translated across settings and disciplines, are often easy to implement, and support person-centered care and patient preferences. Increasingly, evidence supports nonpharmacological interventions and strategies to manage symptoms of AD or slow progression of the disease (Herring et al., 2009; Rodriguez & Verkhratsky, 2011).

In 2007, an interdisciplinary team of health science researchers, led by the late Linda Buettner, authored a white paper summarizing the state of the science related to nonpharmacological strategies to address symptoms of early-stage dementia (Burgener et al., 2007). This paper was recently updated as a series of integrative and systematic reviews that will appear in upcoming issues of Research in Gerontological Nursing. The current commentary highlights examples of recent research offering innovative solutions, examines the implications for nursing practice, and outlines priorities for future research. In much of the research, there was no uniformity in how AD was measured, and many studies likely included both individuals with mild cognitive impairment (MCI) and early-stage dementia, making no distinctions. Although there are important differences between these two diagnoses, for the purpose of the present commentary, study participants (either those with MCI or early-stage AD) are referred to as persons with dementia (PwD), recognizing that as the science of diagnosis moves forward, researchers will differentiate outcomes in these patient populations.

Support Groups

Support groups include one or a combination of emotional support, peer support, and education using both in-person or “virtual” environments. Support group use as a nonpharmacological strategy for improving participants' acceptance of cognitive impairment; performance and satisfaction with meaningful activities; resilience and self-management; and caregivers' levels of coping self-efficacy, perceived support, and preparation and task effectiveness is well documented. In addition, support groups are well accepted by PwD and caregivers. Support groups that are more highly rated by participants are those that facilitate meaningful dialogue and enhanced communication by including both family members and PwD (Steiner, Pierce, & Salvador, 2015).

In general, the underlying mechanism of action is presumed to be social engagement and relieving social isolation, which contributes to cognitive decline (Burgener, Jao, Anderson, & Bossen, 2015). However, a new theoretical framework suggests that improvements in neural plasticity may also be at play. For example, improvements in cognitive function were noted in a support group using education as its major component (Schmitter-Edgecombe & Dyck, 2014), supporting the theory that cognitive stimulation could help the brain reorganize itself by making new neural connections. The addition of bio-imaging outcomes to this area of research would help assess theory validity.

Nutrition

Approximately 25% of PwD are malnourished (Rullier et al., 2014), which is associated with poor health, cognition, and behavioral and psychological symptoms of AD (Rullier, Lagarde, Bouisson, Bergua, & Barberger-Gateau, 2013). Nutritional status is often overlooked in research, yet it may be an important variable. Including a reliable measure of nutritional status, such as the Mini Nutritional Assessment (Vellas et al., 1999) or a biological marker of nutritional adequacy, even in research not specifically addressing nutrition, would increase understanding of the complex relationships between nutritional status and quality of life in PwD and their caregivers.

Recent research has moved from focusing on specific foods or nutrients to examining dietary patterns and the relationship to cognition. For example, DASH (Dietary Approaches to Stop Hypertension) and Mediterranean diets are associated with higher levels of cognition in older adults (Wengreen et al., 2013). The MIND (Mediterranean–DASH diet intervention for neurodegenerative delay) diet score is associated with a slower decline in global cognitive scores than either the DASH or Mediterranean diet scores alone (Morris et al., 2015). These studies show promise that heart healthy diets may also be brain healthy.

Nutrition and mealtime is also a major concern for caregivers. Many caregivers are overwhelmed with daily challenges of mealtimes and believe that health professionals do not address challenges associated with nutrition (Lopez & Amella, 2011). Yet, caregivers are eager to receive information regarding food and nutrition (Anderson, Rose, & Taylor, 2016). Assessment-based nutritional guidance implemented with a personal and positive approach may inspire and empower family members to make positive changes in their diets, leading to an improved nutritional status for PwD and themselves (Puranen, Pitkala, & Suominen, 2015). Moreover, as food and mealtime connects individuals in social and nurturing relationships, the focus should also include assessing and maintaining the meaning of mealtimes for PwD and their caregivers (Lopez & Amella, 2012).

Exercise

Exercise has many undisputed health benefits. Recent research on the impact of aerobic exercise in older adults using magnetic resonance imaging found that exercise increased gray matter volume in the hippocampus (Erickson et al., 2009, 2011). Exercise was also associated with increases in serum levels of brain derived neurotrophic factor (BDNF) and improved spatial memory (Erickson et al., 2009, 2011), executive functioning, and connectivity in critical brain areas (Voss et al., 2010). This line of research holds promise for PwD who may also benefit from exercise. Indeed, a recent review by Nagamatsu et al. (2014) found neuroimaging, behavioral, and biomarker evidence linking exercise with cognitive and brain health motor performance. In addition, a Cochrane review concluded that exercise programs can have a significant impact on improving activities of daily living (ADLs) and cognition (Forbes, Thiessen, Blake, Forbes, & Forbes, 2013). Research suggests that the benefits of exercise come from its ability to reduce insulin resistance and inflammation and stimulate factors that enhance neurogenesis. Although exercise research often measures outcomes such as ADLs and functional independence, the addition of cognitive measures, biomarkers, and bio-imaging may shed light on the effects of exercise related to brain pathways in AD.

Cognitive Training and Stimulation

Cognitive training refers to interventions that guide practice on particular tasks. In laboratory settings, these interventions often include computer-based training that targets timing and coordinating various tasks, such as color identification and mathematical calculations. In home-based research, the tasks often include identifying names and faces and money-related tasks. Cognitive stimulation refers to interventions that increase cognitive and social functioning using nonspecific approaches, such as reality orientation, verbal fluency, and exercises to stimulate encoding and retrieval of episodic memory (Yevchak, Loeb, & Fick, 2008). Overall, findings are promising as these demonstrate that PwD are able to learn new skills, regardless of the type of training.

The mechanisms of action of cognitive training and stimulation have the highest level of evidence as compared with other nonpharmacological interventions (Burgener et al., 2015). Brain imaging reveals activation of parietal, occipital, frontal, and temporal lobes; the cerebellum; and the basal ganglia in response to cognitive training and stimulation. Promising results were also reported from in-home cognitive training, including improvements in the ability to associate names and money-related tasks, such as balancing a checkbook and making change (Tappen & Hain, 2014). Further research that targets behaviors that are valued as important for PwD and their caregivers are warranted, as is research that determines the necessary dose of the interventions and long-term follow up of improvements in cognitive function as compared with controls.

Mind–Body Interventions

Recently, there has been renewed interest in the benefit of mind–body therapies for PwD, such as meditation and mindfulness, reflective exercise (e.g., yoga, tai chi, qigong), biofield or energy healing therapies (e.g., Reiki, Healing Touch, Therapeutic Touch), and guided imagery. Meditation and mindfulness interventions among PwD demonstrate improvements in logical memory (Innes, Selfe, Brown, Rose, & Thompson-Heisterman, 2012), working memory, verbal fluency, and attention (Moss et al., 2012), as well as improvements in sleep (Innes et al., 2012), increased cerebral blood flow (Moss et al., 2012), improved mood (Innes et al., 2012; Moss et al., 2012), and decreased agitation (Reig-Ferrer et al., 2014). Tai chi and yoga also maintain and improve cognitive function in PwD by incorporating mindful movement, and share similar mechanistic actions with aerobic exercise. In addition, guided imagery may help PwD overcome apathy and poor attention, and may provide a meaningful strategy for improving memory. Biofield therapies decrease agitation (Hawranik, Johnston, & Deatrich, 2008) and improve cognitive function and mood in PwD compared with controls (Lu, Hart, Lutgendorf, Oh, & Schilling, 2013). The impact of integrating these therapies with standard treatments and clinical practice is warranted.

Mind–body strategies promote relaxation and decrease stress via psychoneuroimmunological pathways, such as the hypothalamic-pituitary-adrenal axis, which is dysregulated in AD and correlated with behavioral symptoms (McEwen, 2007). Recent studies examining the impact of the relaxation response on the transcriptome report changes in the expression of genes related to inflammation and aging, such as insulin-like growth factor-1, which may play a role in mediating the symptoms exhibited by PwD (Bhasin et al., 2013). These epigenetic effects of mind–body therapies in PwD should be explored further.

Driving Safety

The potentially increased number of drivers with dementia is a cause for national concern. Because driving is a fundamental activity linked with socialization, independent functioning, and well-being, the decision to stop driving raises emotional, legal, and ethical considerations. Cognitive decline in older adults can lead to getting lost while driving, difficulty detecting and avoiding hazards, as well as increased errors. To date, research has focused on assessing driving ability, neuropsychiatric testing and driving performance, factors associated with driving performance and cessation, and interventions for driving and driving cessation. Yet, it is clear that these foci alone will not adequately address this multifaceted problem. Indeed, a Cochrane review concluded that research fails to demonstrate the benefit of driver assessment for preserving mobility or reducing motor vehicle accidents (Martin, Marottoli, & O'Neill, 2013).

However, new technologies, such as self-driving cars and interdisciplinary collaborations, are creating innovative solutions. For example, exciting research is underway at the Massachusetts Institute of Technology (MIT) AgeLab and the New England University Transportation Center at MIT. Sponsored by public and private partnerships, teams are studying transportation safety; the impact of health, wellness, and medication use on operator performance; personal transportation choices; future travel demand; and the promise and trade-offs of new technologies (access http://agelab.mit.edu/transportation-community). Alternatives to driving, such as smarter cars, user-friendly public transportation, ride sharing options, and accessible and dementia-friendly town planning, are underway.

Falls Prevention

Falls are of major concern for PwD and their caregivers. Several studies that followed individuals over 1 year reported fall rates that were approximately double those of the general population (Taylor, Lord, Delbaere, Mikolaizak, & Close, 2012). This risk of falls appears to increase as cognitive function declines (Gleason, Gangnon, Fischer, & Mahoney, 2009), yet fall prevention guidelines for older adults do not include PwD. A recent meta-analysis evaluating the risk for falls in older adults reported that cognitive impairment increased the risk for falls and falls with serious injuries; however, the authors did not identify the level of decline at which risk begins (Muir, Gopaul, & Montero Odasso, 2012).

Assessing balance and gait has become more sophisticated over the past several years, using techniques such as posturography, computerized walkways, and software to determine postural reactions. These methods could be applied to the clinical setting, allowing for the tailoring of fall prevention strategies based on an individual's gait signature. Additional future prevention approaches will be developed as gerontological researchers continue to identify and characterize modulations in gait and balance in relation to cognitive function.

Intervention strategies for reducing falls in PwD should minimize tasks during walking through mindfulness-based approaches. These strategies can also include technological aids, such as nightlights and mobile health, or cognitive training to improve motor function. Given that fear of falling is more prevalent among older adults with dementia compared with older adults without cognitive impairment, strategies should be developed to address this fear. Development and testing of an iconographic measure for PwD might improve screening for falls and provide understanding of the fear of falling experienced by those with cognitive impairment (Delbaere, Close, Taylor, Wesson, & Lord, 2013).

Advance Care Planning

Since the passage of the Patient Self-Determination Act in 1991, advance care planning and the completion of advanced directives have been advocated as a means of confirming that care is consistent with patients' values and preferences. For the past two decades, the primary focus of research and practice has been on ensuring that those near the end of life designate a health care proxy and indicate their preferences for life sustaining treatments, such as resuscitation and feeding tubes. Advance care planning is an integral part of care for PwD so that a plan for their future is developed in a way that respects their wishes for care as their cognitive function declines.

Several effective strategies have been developed to promote advance care planning. The Physician Orders for Life-Sustaining Treatment (POLST; Bomba, Kemp, & Black, 2012) facilitates eliciting preferences regarding life-sustaining care preferences and is widely used in nursing homes across the United States. Recent research suggests that this tool may be equally acceptable across differing racial and ethnic populations (Jennings et al., 2016). In addition, several online resources are available to guide conversations about values and preferences. For example, The Conversation Project (access http://theconversationproject.org) was founded in 2010 to help individuals talk about their wishes for end-of-life care. A guide is available specifically for those with AD and other dementias that uses an innovative strategy for decision making specifically related to dementia (Volandes et al., 2009). Volandes et al. (2009) used either a video depiction of a patient with advanced dementia or a verbal narrative to ascertain treatment preferences. More participants who viewed the video opted for comfort, and their goals of care were more stable over time than those who had the verbal narrative alone. Although the strategy has been applied to other conditions, such as cancer and heart failure, it has not been tested among those with early-stage dementia and the acceptability of such an intervention is debatable.

When looking toward the future, nurse scientists and clinicians are poised to move nursing science and practice forward by expanding the focus of advance care planning from simply documenting preferences about resuscitation and artificial feeding to ensuring that these preferences are translated into high-quality care. For example, recent research suggests that the use of feeding tubes for individuals with advanced dementia decreased by 50% in the past 15 years (Mitchell, Mor, Gozalo, Servadio, & Teno, 2016). This may be good news; however, gerontological nurses must ensure that practice and policy are aligned with high-quality alternatives to aggressive care, such as hand feeding and symptom management.

Future Research Directions

Nonpharmacological interventions hold promise as effective, low-cost, and adaptable strategies for the millions of PwD and their caregivers. As the future of gerontological nursing research and practice in this area is contemplated, several points must be considered to move the science forward in innovative and necessary ways.

First, given that individuals who identify as Latino and African American have an increased risk of AD (Mehta & Yeo, 2016), researchers should include diverse and inclusive study samples. In addition, clinicians should be mindful of the need for culturally congruent education and awareness campaigns and the need to dedicate efforts to promote detection and diagnosis. Similarly, inclusion of sexual/gender minorities is important in both research and practice as lesbian, gay, bisexual, and transgender (LGBT) older adults with dementia can be considered as triply marginalized given their sexual/gender minority status, cognitive impairment, and advancing years. Current research rarely examines how dementia affects the LGBT population (McGovern, 2014), and recent reports from the Institute of Medicine and National Institute on Aging call for examining these health disparities.

Second, the use of mobile health and telehealth technologies may benefit PwD and caregivers, particularly as a method of reaching underserved and rural populations. These technologies may not only bridge clinicians and patients, but also can be used as innovative tools in research. Individuals who engage with others through online support groups indicate a sense of being better informed, having more confidence in relationships with health care providers, and possessing more knowledge about treatment options (van Uden-Kraan, Drossaert, Taal, Seydel, & van de Laar, 2009). Caregivers of PwD who use personal blogs felt socially supported and connected (Anderson, Hundt, Dean, Keim-Malpass, & Lopez, in press). Investigating ways in which PwD and caregivers use online and social media platforms can offer a window into the experience of living with AD that will inform gerontological nursing practice and research.

Third, understanding the mechanisms of action of nonpharmacological interventions for PwD can be enhanced by using bio-imaging and biomarkers. Examining how these interventions exert effects could optimize intervention delivery, provide data to compare effectiveness, identify patient populations most likely to benefit, and pinpoint ways to integrate these interventions with pharmacological treatments to maximize symptom management and quality of life.

Finally, studies of nonpharmacological interventions will require the use of multiple methods. Qualitative methods, for example, can provide rich description to enhance intervention design and understand how interventions are experienced when outcomes are not adequately measured using standard instruments. Given the critical role caregivers and families play in the care of PwD, research that uses dyadic interventions and study designs, as well as those that include measures of family outcomes, are also needed.

It is important that both researchers and clinicians recognize PwD in the earliest stages of the disease because these individuals can optimize their health and change in ways that may help them as the disease progresses. Family caregivers provide the majority of care to PwD and supporting them in these efforts must also be a major priority. Until AD can be prevented or cured, nonpharmacological strategies should be considered for improving the quality of life of PwD and caregivers and helping them find meaningful ways to live with this disease. Gerontological researchers should partner with interprofessional teams and policymakers to ensure the development and translation of strategies at the individual and community levels to address the needs of PwD and their families.

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Authors

Dr. Anderson is Associate Professor and Dr. Rose is McMahan-McKinley Endowed Professor of Gerontology, College of Nursing, University of Tennessee, Knoxville, Tennessee; Dr. Lopez is Professor, Program Director Doctor of Nursing Practice, School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts; and Dr. Specht is Professor Emerita, College of Nursing, University of Iowa, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The authors thank the authors of the original white paper: Elizabeth Beattie, Ann Bossen, Kathleen Buckwalter, Linda Buettner, Sandy Burgener, Donna Fick, Suzanne Fitzsimmons, Ann Kolanowski, Nancy Richeson, Karen Rose, Andrea Schreiner, Janet Specht, and Fang Yu. The authors gratefully acknowledge the leadership of the late Linda Buettner in organizing the group of interdisciplinary researchers who became members of Dementia Day Camp, now known as the International Dementia Scholars Collaborative.

Address correspondence to Karen M. Rose, PhD, RN, FGSA, FAAN, McMahan-McKinley Endowed Professor of Gerontology, College of Nursing, University of Tennessee, 1200 Volunteer Boulevard, Knoxville, TN 37996; e-mail: krose20@utk.edu.

10.3928/19404921-20161209-05

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