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Therapeutic Interventions For Patients

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Question:

Discuss about the Therapeutic Interventions For Patients Of Dementia.
 
 

Answer:

Introduction

Dementia is a broad category of brain disease, affecting person’s ability to recall and identify people. It is a group of symptoms caused by more than 70 disorders in brain, affecting the patients intellectual functioning and gradually decreases his ability to recall. These effects are severe enough to obstruct the patient’s daily activities and relationships (Cipriani et al. 2017). From the first symptom, loss of memory, through the development of behavioral and communal changes, dementia affect person’s quality of life. There is no drug available to cure dementia and related syndromes. However, certain drugs can slower the process of memory loss by combating the symptoms. Hence, to treat such disease clinicians have come up with some non-pharmacological interventions (Kales, Gitlin & Lyketsos, 2015).

While pharmacological interventions are measured and standardized with dose amount, non-pharmacological are difficult to evaluate as it can show different results on two patients. There are different ways to categorize such interventions like depending on the treatment goal, therapeutic approach and so on. Therapeutic goal consists of factors that aims to improve the quality of life and health of the patient suffering from dementia (Cabrera et al., 2015). These interventions rarely are standardized, as standardization needs a large section of patient going through the intervention to see the effects.

In this critical analysis, discussion on such non-pharmacological or therapeutic interventions has been included. The array of therapeutic interventions in dementia-care is broad including daily interactions between care provider and the patient, art related therapies, social and environmental effects, and even animal therapies as well. Hence, in this discussion, cognition focused psychosocial interventions are going to be discussed.

 

Cognition focused approaches

According to Liu, Au and Wong (2017), this intervention is further divided into 4 parts

  • Cognitive stimulus therapy
  • Reminiscence therapy
  • Reality orientation and Validation therapy
  • Cognitive training and Multi-sensory stimulation

Cognitive Stimulation Therapy (CST)

This is one of the several therapeutic interventions used to treat patients with Alzheimer’s or the other dementias. In this therapy, patients are involved in a session with trainer practitioner of interpersonal communication. Session of each day held based on themes such as patient’s favorite food, current affair, memories physical games, number games, usage of money, association of words and so on. Initial sessions are held twice in a week consisting of beginning and maintenance sessions. Hence, it can be stated that the CST includes patient’s respect, choice, fun, and participation by maximizing their potential and ability to recollect (Aguirre et al., 2013).

The prime goal of cognitive stimulation therapy is to create an atmosphere in which patients are able to get educated and strengthen their pre-existing abilities. Hence, they will be able to focus on their capacity to recollect. According to Orrell et al. (2017), evidences suggest that CST sessions given to 180 pair of patients, who went through CST program shown better results as their behavior towards their family and caregivers changed significantly. According to Cove et al., (2014), study on three group of patients also highlights the beneficial effects of CST on dementia care. These three groups were dementia patient with trained caregivers, dementia patient with non-trained caregivers and Control group. Each group were given 14 sessions of weekly CST. However, very less changes was observed in case of group two, whose caregivers were not trained in providing CST. Hence, no improvement was seen in their cognition and quality of life. Whereas the group one showed significant changes in cognition as the caregivers received the training to provide CST. These results also suggest that the duration of such sessions need to be increased as this particular ‘once in a week’ dose may not be enough to prevent the natural corrosion in dementia.

Therefore, from the review of both these studies it is significant that CST is an effective way to treat patient with dementia. There was a noticeable difference between the mental state and behavior of patients with usual medication and patients with CST sessions. Different measures were to identify this finding. First was Mini Mental State Examination (MMSE) and the other one was Alzheimer’s Disease Assessment Scale – Cognition (ADAS-Cog) (Cove et al., 2014). The aim of these tests were to investigate memory and orientation as well as language and visuospatial abilities. These measures were also used in pharmacological trials hence the direct comparison was possible.

 

Reminiscence therapy

Reminiscence Therapy (RT) is consists of discussions of experiences, events and activities with the help of previous photographs, household items, familiar incidents and archives music collection. This discussion can happen with an individual or a group of people trained to do such things. In RT meetings, different groups are involved, where participants are motivated to talk about their past-life once in a week. These are individual sessions where patients are made to recall their life incidences and experiences chronologically and evaluate those incidences (Cotelli, Mnaenti & Zanetti, 2012). Family of those patients are also involved in such therapy, as family is one of the important pillars to provide such therapy. This therapy is a popular psychological intervention for people affected with dementia and has been rated one of the best therapy by participants as well as care providing staff. The aim of this therapy is to target the long-term memory as the prime symptom of dementia is impaired short-term memory and the in maximum cases the long-term memory stays intact. Hence, RT acts as an intervention, which leads people to recall their long-term memory and eventually re-live their happy past life. Hereby, care providers can develop a book or life record of the patient so that they can easily access their own past life.

There are two types of reminiscence therapy. First is simple or general reminiscence. The main aim of such therapy is to help the patient recollect their common memories, developing sociability and educational as well as entertaining sessions. This therapy triggers the topics the participant is interested in; however, the unlikely topics or painful topics are avoided for primary session. Another therapy includes Specific reminiscence therapy that includes small groups or only individual, as according to its name, it is more specific (Subramaniam & Woods, 2012).

According to Chen, Li and Li (2012), RT was imposed on a group of patients and they had to go through six weekly sessions for 90mins. The first session include sharing identities among the group. The procedure for other sessions were almost the same inclusive of three parts: homework, agenda development and review of those, concentrating on reminiscences, feedback, and assignment submission and so on. After such therapy, the primary outcome was decreased symptoms. Other outcomes include higher self-esteem, life satisfaction and decreased loneliness. Another evidence showed same result, where the sample population had mean age greater than 55. The intervention applied to them was weekly 4 sessions for 6 weeks. The outcome was registered after 6th week and the professionals found that patient’s health was recovered as therapy improved their quality of life. They started communicating to caregivers and families that improved their condition. They were able to relate to their own biography hence their ability of cognition was improved (Hofmann et al., 2012).

Hence, from these evidences it can be stated that reminiscence therapy works as a flashback of the past life for the patients with dementia. Involvement of families and friends makes easier for those patients and caregivers to improve. Whether it is an individual session or a group activity primary aim is to connect to the patient’s interest and experience as these plays major roles in care planning process. This therapy helps the patients to increase their social connection and decrease their aggression.

 

Reality Orientation and Validation Therapy

Reality orientation (RO) is a therapy to improve the quality of life in the patients of dementia. However, previously it was used to treat the severely disturbed war prisoners rather than such therapeutic intervention. In this therapy, patient is provided with an overview or presentation of orientation information within which they are informed about the place, time to increase their understanding about the surrounding they are living in. furthermore, this is another way to improve their self-control, self-esteem and social connectivity. There are different forms of this therapy such as usage of calendars, notice boards, cuing and people can be given such therapies in a group or individually as well (Woods, 2014). The caregivers should be sensitive about the condition of the patient as they have impaired cognition and may react to some interventions. They can have difficulties to remember any current event; hence, the caregiver should be polite and ready to face any adverse situation.

Usage of RO as a therapeutic intervention is controversial. According to some experts, it has been applied to some patients mechanically where caregivers were insensitive to the needs of patient. Experts also suggested that patients need to relearn these materials provided in RO as it helps to improve their mood and self-esteem. Furthermore, less psychiatric interventions uses such therapy to treat patients. Hence, to prove the application of this therapy as an intervention for dementia, evidences need to be provided.

Evidences from a systematic review to check the effectiveness of the Reality Orientation was taken. The review included 43 studies and from that six-review paper were taken as they match the criteria. Length of the RO session was diverse, some sessions lasted 30 minutes for five times a week, and some lasted 45 minutes twice a week (Aguirre et al., 2013). Results from those papers suggested that RO therapy significantly affected the cognition and behavioral aspects of patient and was in favor of the patient. It also indicated that the RO therapy benefited the patient’s mood and self-esteem. However, longer sessions and continuous therapy was needed.

Naomi Feil first developed validation therapy. The discovery of this therapy was a result of shortcoming of other therapies like Cognition therapy, reminiscence therapy and reality orientation as these therapies were applied to a patient, who had advanced level of dementia. Naomi Feil classified the symptoms and level of dementia according to the patients cognition reach and developed symptoms (Feil, 2014). The development was a result of solutions created to address the problems of patients and caregivers while treating advanced level dementia. In such therapy, the Caregiver attempts to connect with the patient by understanding his/her feeling and relating that with his/her behavioral and vocal indications. This therapy targets to understand the patient’s feelings and try to validate those for betterment of the patient. The prime aim is to keep the patient happy in any situation, as advanced stage of dementia leads them to feel or see delusions, which makes them distressed (Gitlin, Kales & Lyketsos, 2012).

Some important features of this therapy includes initially the caregiver tries to classify the behavior of patient and then other interventions are applied. Application of these interventions depends on the complexity of the disease that is different for each individual. It is classified in four stages: Repetitive motions, Confusion related to time, mal orientation, and finally vegetation. All these steps are identifies by different cognition levels and behavior features upon which the intervention depends (Jones & Miesen, 2014).

Studies from various experiments suggested that there are numerous positive effects of validation therapy. Effects depends on the number of validation session patients receive and amount of interactions they go through per week. However, there are few studies, which did not find any significant effect on patient.

 

Cognitive training and Multi-sensory stimulation

The fundamental idea of Cognitive training is to improve the patient’s ability to recall.and that can be achieved by repetitive practice of cognition functioning. This training helps to develop the knowledge strategies through which the patient can receive such information. Hence, through continuous practice of these daily tasks and will power of patients to live an independent life, conditions of patients are supposed to be improved. This therapy can be individualized or may be carried out in a group (Bahar?Fuchs, Clare & Woods, 2013). Daily tasks can be made up of intelligence materials including pictorial materials, sequential images and logical tasks like cube task, row formation and ability to note task. Other tasks includes ability to recognize, search, solve small arithmetical questions perception of speed and so on. These therapies are applied in modern day cognitive training, which represents the behavioral therapy for patients with dementia.

Evidences to prove the effectiveness of this therapy includes different variety of methods for different people. There is no specific process dedicated to this therapy hence period of therapy, process of application, measurements of results are different for every patient. Hence, generally there is only few amount of methods where studies on a large population is present (Unverzagt et al., 2012). As a result, it can be stated that firstly results are of very narrow spectrum as randomized methods are less. Secondly, most of the methods are controversial and lastly array of dementia for every patient is so different that drawing comparison between them is quite problematic. Hence, applying this intervention is under research and needs further experimentation.

Multi-sensory stimulations are therapies, which helps the patients of dementia to control their senses that is touch, smell, sight, hear and taste by evoking positive feelings. This therapy was discovered to treat patients with learning disabilities in late 1960s (Brodaty & Burns, 2012). It created an environment by providing safe and enjoyable activities in which people can learn freely. However, nowadays it is used to treat Alzheimer’s, dementia, autism and many more disabilities. In case of advanced dementia, patient’s ability to communicate and carry out the daily activities decreases. This therapy provides them a way to reconnect by letting them express themselves, as at that period they are unable to do so with words. It makes them feel safe and relax and improves their self-esteem, mood and consequently their health improves (Lykkeslet et al., 2014).

According to the Canadian Association of Occupational Therapist (CAOT), application of such therapy should be with familiar objects and should target one sense at a time. Objects includes familiar clothes and foods, natural materials like fruits and flowers and materials, which are sensory rich like perfumes, grooming tools and so on. This therapy is applied in a long residential care set up as patients at that stage suffers from agitation and restlessness. According to Maseda et al. (2014). Evidence has shown that this therapy, when applied to a small group of patient and for a prolonged period, showed better results. However, these results varied among patients, as the stage of dementia they were suffering from was different.

Conclusion

Dementia is one of the fastest growing mental disorder affecting older adults. While there is no medicine available to treat dementia effectively, usage of non-pharmacological or therapeutic intervention can be used to treat such patients. This critical analysis has indicated four interventions, which can improve the state of patients with dementia. Cognitive therapy focused the person’s ability to recollect the pieces of his past and create an autobiography to improve his present condition. Evidences also supported that this therapy has positive effects on dementia. Reminiscence therapy, which involves the patient in meetings and discussions to talk about their experiences, also effected the person’s self-esteem and mood positively. Other intervention discussed was reality orientation and validation therapy. However, evidences does not support this therapy as it depends on the stage of disease and group of patient. Lastly, multi-sensory therapy and cognitive training was included, which helps the last stage dementia patient to communicate with society, as they are unable to express their selves.

 

References

Aguirre, E., Hoare, Z., Streater, A., Spector, A., Woods, B., Hoe, J., & Orrell, M. (2013). Cognitive stimulation therapy (CST) for people with dementia—who benefits most?. International journal of geriatric psychiatry, 28(3), 284-290.

Bahar?Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia. The Cochrane Library.

Brodaty, H., & Burns, K. (2012). Nonpharmacological management of apathy in dementia: a systematic review. The American Journal of Geriatric Psychiatry, 20(7), 549-564.

Cabrera, E., Sutcliffe, C., Verbeek, H., Saks, K., Soto-Martin, M., Meyer, G., ... & RightTimePlaceCare Consortium. (2015). Non-pharmacological interventions as a best practice strategy in people with dementia living in nursing homes. A systematic review. European Geriatric Medicine, 6(2), 134-150.

Chen, T. J., Li, H. J., & Li, J. (2012). The effects of reminiscence therapy on depressive symptoms of Chinese elderly: study protocol of a randomized controlled trial. BMC psychiatry, 12(1), 189.

Cipriani, J., Benz, A., Holmgren, A., Kinter, D., McGarry, J. and Rufino, G., 2017. A systematic review of the effects of horticultural therapy on persons with mental health conditions. Occupational Therapy in Mental Health, 33(1), pp.47-69.

Cotelli, M., Manenti, R., & Zanetti, O. (2012). Reminiscence therapy in dementia: A review. Maturitas, 72(3), 203-205.

Cove, J., Jacobi, N., Donovan, H., Orrell, M., Stott, J., & Spector, A. (2014). Effectiveness of weekly cognitive stimulation therapy for people with dementia and the additional impact of enhancing cognitive stimulation therapy with a carer training program. Clinical interventions in aging, 9, 2143.

Feil, N. (2014). Validation therapy with late-onset dementia populations. Caregiving in dementia: Research and applications, 1, 199-218.

Gitlin, L. N., Kales, H. C., & Lyketsos, C. G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. Jama, 308(19), 2020-2029.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive therapy and research, 36(5), 427-440.

Jones, G. M., & Miesen, B. M. (Eds.). (2014). Care-Giving in Dementia: Volume 1: Research and Applications. Routledge.

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. bmj, 350(7), h369.

Liu, T., Au, C. L. A., & Wong, G. H. Y. (2017). Cognitive Stimulation Therapy (CST) for Dementia.

Lykkeslet, E., Gjengedal, E., Skrondal, T., & Storjord, M. B. (2014). Sensory stimulation—a way of creating mutual relations in dementia care. International journal of qualitative studies on health and well-being, 9(1), 23888.

Maseda, A., Sánchez, A., Marante, M. P., González-Abraldes, I., Buján, A., & Millán-Calenti, J. C. (2014). Effects of multisensory stimulation on a sample of institutionalized elderly people with dementia diagnosis: a controlled longitudinal trial. American Journal of Alzheimer's Disease & Other Dementias®, 29(5), 463-473.

Orrell, M., Yates, L., Leung, P., Kang, S., Hoare, Z., Whitaker, C., ... & Pearson, S. (2017). The impact of individual Cognitive Stimulation Therapy (iCST) on cognition, quality of life, caregiver health, and family relationships in dementia: A randomised controlled trial. PLoS medicine, 14(3), e1002269.

Subramaniam, P., & Woods, B. (2012). The impact of individual reminiscence therapy for people with dementia: systematic review. Expert Review of Neurotherapeutics, 12(5), 545-555.

Unverzagt, F. W., Guey, L. T., Jones, R. N., Marsiske, M., King, J. W., Wadley, V. G., ... & Tennstedt, S. L. (2012). ACTIVE cognitive training and rates of incident dementia. Journal of the International Neuropsychological Society, 18(4), 669-677.

Woods, B. (2014). reality orientation?. Care-Giving in Dementia: Volume 1: Research and Applications, 121.

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