Management of Neuropsychiatric Symptoms of Dementia

Several presentations discussed the management of neuropyschiatric symptoms (NPS) associated with dementia, an issue that is of particular concern in the long-term care (LTC) setting. NPS may vary as a function of time of day, a common clinical phenomenon known as “sundowning syndrome,” characterized by the emergence or exacerbation of NPS in the late afternoon, evening, or at night.

Ovidiu Lungu, PhD (Centre for Research in Aging – Donald Berman Maimonides Geriatric Centre and University of Montreal, Montreal, QC, Canada), and colleagues assessed the frequency and severity of NPS over a 2-week period using the Neuropsychiatric Inventory – Nursing Home version. Frontline nursing staff who provide direct resident care evaluated 97 LTC residents with dementia. Complete data across all shifts was collected for 59 residents. The results showed that the composition of NPS subsyndromes changed across the circadian cycle. During the day, hyperactivity and agitation-related NPS were most significant and appeared to cluster with mood and pyschosis. In the evening and at night, mood- and psychosis-related subsyndromes dominated. These results suggest that NPS evaluation and management strategies should be adapted to time of day.

Many of the presentations highlighted the importance of non-pharmacological interventions for managing NPS of dementia. Some patients may not respond to pharmacological interventions, and non-pharmacological approaches are an important component of person-centered care. In their presentation, Eileen L. Sullivan and her colleagues from St. Joseph’s University, Philadelphia, PA, reviewed some of the interventions that have been effective for managing NPS of Alzheimer’s disease; including bright light therapy, music therapy, and art therapy. Even just providing patients with the opportunity to observe art can lower agitation and anxiety levels. Other creative expression programs found to be effective in reducing NPS of dementia include life story writing and sharing groups, such as the Timeslips™ program, which is a group storytelling program that encourages creative expression among people with dementia. Sullivan’s group presented the findings of a pilot study to implement such a program at the St. Ignatius Nursing and Rehabilitation home in Philadelphia, PA. Within each session, and across the six-week timespan of the study, patients showed reduced symptoms of agitation and anxiety as measured by the Overt Agitation Severity Scale.

Music therapy has been shown to decrease NPS associated with Alzheimer’s disease—agitation in particular. However, the availability of music therapy services in the nursing home setting is often limited or only temporary. Kendra Ray (Drexel University, Philadelphia, PA) and Jan Maier (RTI International, Boston, MA) implemented a program to overcome this challenge by training certified nursing assistants (CNAs) to provide music-based activities in the nursing home. In three long-term care facilities in Brooklyn, NY, 24 residents participated in an intervention provided by music therapists, followed by music-based programming once per week provided by CNAs. The researchers used the Cohen-Mansfield Agitation Inventory (CMAI) to measure changes in agitation levels as a result of the intervention and found that symptoms of agitation gradually declined and had decreased significantly by the end of the study. Their findings suggest that the services provided by music therapists can be sustained in the long-term care setting through prescribed programs created specifically for trained CNAs to facilitate.

Dallas Seitz, MD, PhD, and researchers at Queen’s University, Kingston, ON, Canada, evaluated the effects of volunteer visits on NPS among LTC residents with dementia. Volunteers were recruited from community advertisements and were provided with training on dementia prior to volunteering. Sixty-three residents, all of whom were diagnosed with dementia and had significant symptoms of agitation, either participated in the volunteer visitor program (n=47), receiving up to three volunteer visits per week over 12 weeks, or received usual care (n=16). Residents who participated in the program showed a significant reduction in scores on the CMAI, whereas residents who did not participate showed no significant change in their scores. However, the study failed to show a significant difference in scores between the groups. No significant differences were found on other measures of NPS, depression, quality of life, or nursing stress. The lack of a statistically significant effect may have been due to the study’s small sample, although the authors suggest that more intensive interventions may be required for this patient population.