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