Nonpharmacological interventions for psychotic symptoms in people with dementia

Abstract

Abstract Background: Psychotic symptoms are common in people with dementia. They are associated with an increased burden of care and higher rates of institutionalisation. Pharmacological interventions lack sufficient efficacy and are associated with numerous deleterious side effects. The present thesis aims to build a rationale and an evidence base to enable the development of a non-pharmacological intervention specifically targeting psychotic symptoms in people with dementia, to provide an effective and safer alternative to current pharmacological treatments. Methods: Two empirical studies were conducted to determine whether psychotic symptoms in people with dementia are associated with reduced quality of life in community dwelling individuals and people living in nursing homes. A Delphi study, incorporating a detailed scoping review, was conducted to identify the best nonpharmacological intervention that could be readily adapted to target psychotic symptoms in people with dementia. Study 1: Impact of psychotic symptoms on living well in people with dementia living in the community This study aimed to investigate whether psychotic symptoms impact the ability of community-dwelling people with dementia to live well by assessing three outcome measures: quality of life (QoL), wellbeing and life satisfaction. The analysis was conducted on cross-sectional data from 1257 community-dwelling people with dementia and their caregivers, using data from the “Improving the experience of Dementia and Enhancing Active Life (IDEAL)” study cohort. This cohort consists mainly of individuals with mild dementia. The study examined differences on three validated measures of living well - Quality of Life in Alzheimer’s Disease scale, World Health Organization-Five Well-being Index and Satisfaction with Life Scale – for people with dementia experiencing or not experiencing delusions and for people with dementia experiencing or not experiencing auditory hallucinations. Analysis of co-variance was used to determine the confounding contributions of cognition (assessed with the Mini-Mental State Examination), depression (assessed with the Geriatric Depression Scale-10), caregivers stress *assessed with the Relative Stress Scale) and antipsychotic usage. Delusions were not associated with more impaired QoL, reduced wellbeing or altered satisfaction with life. The presence of auditory hallucinations was however associated with lower scores for QoL [p<0.001, η2=0.013], wellbeing [p<0.001, η2=0.016] and satisfaction with life [p<0.001, η2=0.010]. After controlling for confounding factors, the relationship between auditory hallucinations and QoL [p=0.003, pη2= 0.011] and wellbeing [p <0.001, pη2= 0.018] remained significant, but there was no significant association with satisfaction with life. In summary, the presence of auditory hallucinations but not delusions were associated with lower QoL and wellbeing in people with dementia living in the community. The results help refine a treatment target for a non-pharmacological therapy for the treatment of a key psychotic symptom in people with dementia Study 2: Impact of psychotic symptoms and concurrent neuropsychiatric symptoms on QoL in people with dementia living in nursing homes This study aimed to investigate whether psychotic symptoms had an impact on QoL in people with dementia living in nursing homes. Cross-sectional data from971 people with dementia was obtained from the “Improving Well-being and Health for people with dementia (WHELD)” study, a cohort exclusively consisting of people with dementia living in nursing homes. Additionally, this chapter investigates the mediating impact of other concurrent neuropsychiatric symptoms QoL. The Neuropsychiatric Inventory - Nursing Home (NPI-NH) version was completed by informant interview. The study compared mean differences in proxy-rated QoL scores (DEMQOL-Proxy) for people with dementia experiencing or not experiencing delusions and for people with dementia experiencing or not experiencing hallucinations. Backward multiple regression was used to determine the added contributions of agitation (Cohen-Mansfield Agitation Inventory), anxiety (NPI-NH-Anxiety), depression (Cornell Scale for Depression in Dementia), dementia severity (Clinical Dementia Rating – sum of boxes score), pain (Abbey Pain Scale) and antipsychotic prescription. Mediation analysis was conducted for agitation, anxiety and depression. The presence of both delusions (p<0.001, B = -8.39) and hallucinations (p<0.00, B = -7.78) was associated with more impaired QoL. Both associations remained significant after controlling for other factors. Agitation, anxiety and depression partially mediated the relationship between each psychotic symptom and QoL. In summary, delusions and hallucinations in people with dementia are associated with more impaired QoL among people with dementia living in nursing homes. The effects remain significant after adjusting for confounding variables. Direct effects of each symptom-maintained significance, with further significant mediation from concurrent neuropsychiatric symptoms. Study 3: Adapting nonpharmacological interventions to manage psychotic symptoms in dementia: a Delphi study This study aimed to determine which nonpharmacological interventions could be best adapted to target psychotic symptoms in people with dementia. Nonpharmacological interventions are recommended as the first line option for treatment, however there is a paucity of evidence for any specific nonpharmacological interventions to primarily target psychotic symptoms. A modified Delphi process was used in the study to establish a consensus from a panel of experts, identify which interventions would most be suitable for adaption. Two rounds of feedback were conducted, and a directed scoping review was undertaken. The expert panel included 12 members with clinical and research expertise in managing psychotic symptoms in people with dementia The study was not able to reach consensus regarding which nonpharmacological treatment could be most readily adaptable to manage psychotic symptoms. However, there were three top nominated treatment options: cognitive behavioural therapy (CBT), family intervention, and environmental/sensory interventions. The suggestions focused strongly on assessing individual situations and triggers, with a further recommendation for a combination of nonpharmacological treatments to be used depending upon the specific needs of an individual with dementia experiencing psychotic symptoms. In summary, whilst consensus could not be reached, there were clear recommendations for three nonpharmacological options to be adapted and clear suggestion for a combination of options to be implemented depending on individual circumstances. General result summary: In people with dementia living in the community, auditory hallucination but not delusions were associated with reduced quality of life. In people with dementia living in nursing homes both delusions and hallucinations were associated with lower quality of life. The Delphi identified 3 therapeutic approaches for possible adaptation of the treatment of psychosis in people with Alzheimer’s disease: cognitive behavioural therapy, family intervention and environmental intervention. Conclusions and Implications: Psychotic symptom are associated with reduced quality of life for people with dementia dwelling in the community and or people with dementia living in nursing homes. The different environments and the different severity of dementia across these two settings has important implications with respect to the selection of the most appropriate psychological intervention and the types of adaptation that will need to be made. It is likely that the development of the interventions suggested by the Delphi will need to be undertaken in several different ways to ensure they are adapted to the needs of the different groups of individuals