Long-Term Partnerships in Lewy Body Dementias

Long-term partnerships are important as they can determine happiness, influence physical and mental health and lengthen one’s lifespan. However, complex neurodegenerative conditions, such as Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB), can disrupt long-term relationships and even lead to dissolution of the partnership. The majority of studies in this field have focused on exploring the effect of PDD and DLB on care partners’ outcomes but the impact of these conditions on dyadic, long term relationships is less well understood. We conducted a series of studies with people with PDD or DLB and their caregiving life partners using quantitative and qualitative methods. We demonstrated that PDD and DLB has a tremendous impact on the caregiving life partners and reduces relationship satisfaction. We argue for more studies in this field and recommend that future research focuses on strengthening dyadic relationships, which can ultimately preserve relationships and delay institutionalisation of the person with PDD and DLB, which has cost saving implications

Saint Simeon the Stylite: A Psychiatric Examination of the Life of a Fifth Century Monk

Religion is now the focus of more attention in psychiatry. This paper examines the life of the fifth century monk, Simeon the Stylite, from a contemporary psychiatric perspective. Such a retrospective examination presents difficulties with regard to the diagnosis of possible psychotic phenomena. A further examination presents difficulties with regard to the diagnosis of possible psychotic phenomena. A further problem is trying to distinguish between a religious and a psychiatric interpretation of particular experiences. The authors outline the life of Simeon and some contemporary opinions. They agree with Kroll and deGanck that great caution is needed in the psychiatric interpretation and examination of an historical or religious life. This paper details some of these difficulties to help determine whether an understanding derived from modern psychiatry is relevant to a different era

Cognitive training interventions for dementia and mild cognitive impairment in Parkinson's disease

Background Approximately 60% to 80% of people with Parkinson's disease (PD) experience cognitive impairment that impacts on their quality of life. Cognitive decline is a core feature of the disease and can often present before the onset of motor symptoms. Cognitive training may be a useful non‐pharmacological intervention that could help to maintain or improve cognition and quality of life for people with PD dementia (PDD) or PD‐related mild cognitive impairment (PD‐MCI). Objectives To determine whether cognitive training (targeting single or multiple domains) improves cognition in people with PDD and PD‐MCI or other clearly defined forms of cognitive impairment in people with PD. Search methods We searched the Cochrane Dementia and Cognitive Improvement Group Trials Register (8 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO. We searched reference lists and trial registers, searched relevant reviews in the area and conference proceedings. We also contacted experts for clarifications on data and ongoing trials. Selection criteria We included randomised controlled trials where the participants had PDD or PD‐MCI, and where the intervention was intended to train general or specific areas of cognitive function, targeting either a single domain or multiple domains of cognition, and was compared to a control condition. Multicomponent interventions that also included motor or other elements were considered eligible. Data collection and analysis Two review authors independently screened titles, abstracts, and full‐text articles for inclusion in the review. Two review authors also independently undertook extraction of data and assessment of methodological quality. We used GRADE methods to assess the overall quality of the evidence. Main results Seven studies with a total of 225 participants met the inclusion criteria for this review. All seven studies compared the effects of a cognitive training intervention to a control intervention at the end of treatment periods lasting four to eight weeks. Six studies included people with PD living in the community. These six studies recruited people with single‐domain (executive) or multiple‐domain mild cognitive impairment in PD. Four of these studies identified participants with MCI using established diagnostic criteria, and two included both people with PD‐MCI and people with PD who were not cognitively impaired. One study recruited people with a diagnosis of PD dementia who were living in long‐term care settings. The cognitive training intervention in three studies targeted a single cognitive domain, whilst in four studies multiple domains of cognitive function were targeted. The comparison groups either received no intervention or took part in recreational activities (sports, music, arts), speech or language exercises, computerised motor therapy, or motor rehabilitation combined with recreational activity. We found no clear evidence that cognitive training improved global cognition. Although cognitive training was associated with higher scores on global cognition at the end of treatment, the result was imprecise and not statistically significant (6 trials, 178 participants, standardised mean difference (SMD) 0.28, 95% confidence interval (CI) −0.03 to 0.59; low‐certainty evidence). There was no evidence of a difference at the end of treatment between cognitive training and control interventions on executive function (5 trials, 112 participants; SMD 0.10, 95% CI −0.28 to 0.48; low‐certainty evidence) or visual processing (3 trials, 64 participants; SMD 0.30, 95% CI −0.21 to 0.81; low‐certainty evidence). The evidence favoured the cognitive training group on attention (5 trials, 160 participants; SMD 0.36, 95% CI 0.03 to 0.68; low‐certainty evidence) and verbal memory (5 trials, 160 participants; SMD 0.37, 95% CI 0.04 to 0.69; low‐certainty evidence), but these effects were less certain in sensitivity analyses that excluded a study in which only a minority of the sample were cognitively impaired. There was no evidence of differences between treatment and control groups in activities of daily living (3 trials, 67 participants; SMD 0.03, 95% CI −0.47 to 0.53; low‐certainty evidence) or quality of life (5 trials, 147 participants; SMD −0.01, 95% CI −0.35 to 0.33; low‐certainty evidence). There was very little information on adverse events. We considered the certainty of the evidence for all outcomes to be low due to risk of bias in the included studies and imprecision of the results. We identified six ongoing trials recruiting participants with PD‐MCI, but no ongoing trials of cognitive training for people with PDD. Authors' conclusions This review found no evidence that people with PD‐MCI or PDD who receive cognitive training for four to eight weeks experience any important cognitive improvements at the end of training. However, this conclusion was based on a small number of studies with few participants, limitations of study design and execution, and imprecise results. There is a need for more robust, adequately powered studies of cognitive training before conclusions can be drawn about the effectiveness of cognitive training for people with PDD and PD‐MCI. Studies should use formal criteria to diagnose cognitive impairments, and there is a particular need for more studies testing the efficacy of cognitive training in people with PDD

Implementation processes in a cognitive rehabilitation intervention for people with dementia: a complexity-informed qualitative analysis

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ. https://creativecommons.org/licenses/by/4.0/Objectives: Healthcare is often delivered through complex interventions. Understanding how to implement these successfully is important for optimising services. This article demonstrates how the complexity theory concept of ‘self-organisation’ can inform implementation, drawing on a process evaluation within a randomised controlled trial of the GREAT (Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer’s and related dementias: a multi-centre single-blind randomised controlled Trial) intervention which compared a cognitive rehabilitation intervention for people with dementia with usual treatment. Design: A process evaluation examined experiences of GREAT therapists and participants receiving the intervention, through thematic analysis of a focus group with therapists and interviews with participants and their carers. Therapy records of participants receiving the intervention were also analysed using adapted framework analysis. Analysis adopted a critical realist perspective and a deductive-inductive approach to identify patterns in how the intervention operated. Setting: The GREAT intervention was delivered through home visits by therapists, in eight regions in the UK. Participants: Six therapists took part in a focus group, interviews were conducted with 25 participants and 26 carers, and therapy logs for 50 participants were analysed. Intervention: A 16-week cognitive rehabilitation programme for people with mild-to-moderate dementia. Results: ‘Self-organisation’ of the intervention occurred through adaptations made by therapists. Adaptations included simplifying the intervention for people with greater cognitive impairment, and extending it to meet additional needs. Relational work by therapists produced an emergent outcome of ‘social support’. Self-organised aspects of the intervention were less visible than formal components, but were important aspects of how it operated during the trial. This understanding can help to inform future implementation. Conclusions: Researchers are increasingly adopting complexity theory to understand interventions. This study extends the application of complexity theory by demonstrating how ‘self-organisation’ was a useful concept for understanding aspects of the intervention that would have been missed by focusing on formal intervention components. Analysis of self-organisation could enhance future process evaluations and implementation studies. Trial registration number: ISRCTN21027481.Peer reviewedFinal Published versio

Psychological interventions for people with Parkinson’s disease in the early 2020s:Where do we stand?

Purpose To explore the heterogeneity of the literature on psychological interventions for psychological difficulties in people with Parkinson’s disease (PD). Methods A scoping review was performed across five major databases (MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library) up to June 2020. Results From an initial return of 4911 citations, 56 studies were included, of which 21 were RCTs. A relatively wide range of therapeutic models have been adopted with people with PD, from common therapies such as cognitive behavioural therapy (CBT) and mindfulness, to less frequent approaches, for example, acceptance and commitment therapy (ACT) and psychodrama. The clinical implications of the findings are discussed, and suggestions are provided for future research on intervention studies and key psychological outcomes. Conclusions CBT appears to be effective in treating depression and sleep disorders in people with PD, while psychoeducation programmes alone should be avoided. The use of CBT to improve anxiety, quality of life, and impulse control, as well mindfulness‐based interventions, should be undertaken with some caution because of insufficient research and inconsistent results. As we enter the new decade, more high‐quality evidence is required for psychological interventions in people with PD in general and to corroborate preliminary positive findings on the adoption of less frequent approaches such as ACT. Practitioner points - Parkinson’s disease is a progressive neurodegenerative condition associated with several psychological difficulties which be targeted by psychological interventions. - Currently, cognitive behavioural therapy (CBT) can be recommended to treat depression and sleep disorders in people with Parkinson’s, while psychoeducation alone should be avoided. - Caution is advised regarding the use of CBT and mindfulness‐based interventions to improve anxiety, quality of life, and impulse control. - Further evidence is required for less common approaches, such as acceptance and commitment therapy, psychodrama, and EMDR