Introduction
A recent report of the International Longevity Center-UK (ILC-UK) indicated that dementia can no longer be viewed as an isolated disorder due to a high prevalence of medical comorbidities, often undiagnosed, associated with it (Scrutton & Brancati, 2016). Patients with dementia also had received a less coordinated comorbidity treatments, resulting to the faster decline of their daily functioning, a reduction in their quality of life (QOL), and earlier mortality events than patients with these comorbidities, but in the absence of dementia.
The report also noted other important findings, which exacerbated the need for better therapeutic options in dealing with dementia, such as: an increase in economic costs; many comorbidities had been preventable; late comorbidity diagnoses (e.g. already with severe symptoms); and 40 percent of age 70 patients had unplanned acute hospital admissions (Scrutton & Brancati, 2016). The state of therapeutic advancement for dementia, although had been enormous already, remained inadequate to the task at hand.
Moreover, the ILC-UK managed to identify six key factors that had been instrumental in the inadequate health outcomes on patients with dementia and expressed comorbidities, such as: atypical symptoms (which resulted to poor and non-comprehensive diagnoses); poor patient-physician and inter-medical care provider communication (which resulted to low standards of care); healthcare system failure in holistic individual care (which resulted to fragmented care); inter-carer knowledge gap (which significantly limited the effectiveness of treatment plans); meagre medication management (which resulted from inadequate empirical support); poor self-management support (which resulted to patient helplessness); and poor comorbidity monitoring (which rendered treatment plans inadequate) (Scrutton & Brancati, 2016). In UK, three comorbidities had been well studied: depression (particularly in patients with Alzheimer’s disease); diabetes mellitus (with DM type as potentially underdiagnosed); and urinary tract infections (41% cause of hospital admissions).
Dementia can be manifested in various neurodevelopmental diseases and other diverse disorders, such as the Alzheimer’s disease, vascular dementia, frontotemporal lobar dementia (FTLD), Parkinson’s disease (Lewy body dementia), Creutzfeldt-Jakob disease, and normal pressure hydrocephalus (Zdanys, et al., 2016; Alzheimer’s Association, 2016). Specific etiologies, diseases or disorders demand often unique therapeutic interventions, without which the treatment plans can prove inadequate and essentially ineffective. In fact, their symptoms can so overlap diagnosis can be problematic and significantly challenging.
This individual programmatic assessment focuses on dementia as a syndrome of Alzheimer’s disease, its behavioral and psychological symptoms, and three modalities of treatment (cognitive, pharmacologic, and alternative or behavioral). Overall, non-pharmacological interventions (e.g. cognitive and alternative) had shown statistically significant improvement in dementia behavioral and psychological symptoms (BPS) (Brodaty & Bums, 2012). Meanwhile, Zdanys, et al. (2016) noted that current medications used in managing dementia BPS are associated with significant adverse reactions, particularly among the elderly, while unable to stop or slow down progress (Alzheimer’s Association, 2016). Alternative approaches, behavioral modalities with no active psychotherapeutic component, range from aromatherapy to animal-assisted therapy (Turner, 2016).
Specifically, cognitive behavior therapy (CBT) is reviewed in this paper as a representative therapeutic intervention among diverse cognitive non-pharmacological treatment modalities, while cognitive enhancers, such as acetylcholinesterase inhibitors, are chosen to represent the conventional pharmacological therapeutic modalities primarily on their cognitive effects, allowing comparability with CBT. Meanwhile, music therapy, a non-psychotherapeutic non-pharmacological modality, appeared to be most-studied and potentially long-lasting in their therapeutic benefits than other modalities.
Certain limitations, however, must be indicated at this point. Unique symptoms associated with other comorbidities are intentionally ignored in the pursuit of simplicity and focus but are mentioned with precision and clarity when necessary, particularly in relation to classic dementia symptoms. Moreover, the specific therapeutic treatments selected to represent the three classes of therapeutic intervention modalities may not be the best options available today. However, they were evidently the most studied in the last decade, which indicates a better understanding on their therapeutic properties than other options.
Dementia from Alzheimer’s Disease
Dementia is a neurological disorder often caused by Alzheimer’s disease, a degenerative brain disease associated largely with old age, which is inherently a consequence of neuronal damage or destruction (Alzheimer’s Association, 2016). It is characteristically identified for the decline in “memory, language, problem-solving, and other cognitive skills”, which inevitably impact the person’s ordinary performance of daily activities. Despite the progressive disturbance of many higher functions, consciousness, however, remains unimpaired (Turner, 2016). In the United States alone, 81 percent of Americans with at least an age of 75 had been diagnosed for Alzheimer’s disease (Alzheimer’s Association, 2016).
Symptomatology
Dementia from Alzheimer’s disease consists of a heterogeneous range of symptoms (a syndrome), which include “psychological reactions, psychiatric symptoms, and burdensome behaviors” (Zdanys, et al., 2016). These symptoms had been found observable in at least 60 percent of dementia-diagnosed elderly in community dwellings and 80 percent of those in long-term care (LTC) facilities. Some symptoms (e.g. geriatric depression), however, precede the dementia diagnosis and are considered as independent risk factors and prodromes for the Alzheimer’s disease itself (Steffens, 2008). Zdanys, et al. (2016) categorized the dementia BPS into three groups: affective; psychotic; and other neuropsychiatric symptoms.
Affective symptoms, the most common symptoms in dementia (Tampi et al., 2011), include depression, anxiety, apathy, and irritability (Zdanys, et al., 2016). Along with apathy, depression is the most common of the affective symptoms manifested in dementia patients with Alzheimer’s disease (Scrutton & Brancati, 2016). The interaction between depression and dementia, however, is complex, each overlapping that of the other and each had been found causing, or a risk factor of, the other, making diagnosis more complicated.
Meanwhile, psychotic symptoms include delusions and hallucinations (Zdanys, et al., 2016), while other neuropsychiatric symptoms include motor symptoms (e.g. wandering, pacing, etc.) (Zdanys, et al., 2016). All these symptoms may either be chronic or acute, primary or secondary, and currently remained to be studied in full if at all.
The assessment of dementia requires a long process, involving various steps. Zdanys, et al. (2016) suggested a rough four-step process with each process demanding a data gathering approach, which must be as comprehensive as possible. First, a thorough history (e.g. medical, psychiatric, activities of daily living, substance use, family, social, etc.) must be obtained to narrow the differential etiological diagnosis from various dementia disorders (Zdanys, et al., 2016). Second, a thorough physical examination must follow to determine active clinical (e.g. neurological or psychological) disorders (Zdanys, et al., 2016).
The third step involves an array of laboratory studies that must be ordered to determine the clinical bases of ongoing symptoms (Zdanys, et al., 2016). Other studies, such as neuroimaging (e.g. computer tomography scan or magnetic resonance imaging), may not be ordinarily indicated but may be necessary on a case to case basis. Lastly, standardized clinical assessments, however, are necessary. Zdanys, et al. (2016) recommended such standardized tools as the Behavioral Pathology in Alzheimer’s Disease Scale (BPADS) (which is the most commonly used tool for Alzheimer’s disease), the Neuropsychiatry Inventory (NPI), the Cohen-Mansfield Agitation Inventory (CMAI), and the Consortium to Establish a Registry for Alzheimer’s Disease Behavior Rating Scale for Dementia (CERADBRSD). However, it may not be feasible to use all tools in a single patient all together. A selection of the most useful ones, including BPADS, is necessary though.
Management: General Principles
The goal in the management of dementia BPS is evidently the reduction of negative outcomes to better improve patient (and caregiver) safety, long-term prospects, and the QOL (Zdanys, et al., 2016). Management involves the treatment of underlying psychological, medical, and neurological disorders, whether primary or secondary to dementia in Alzheimer’s disease, and, when necessary, in three therapeutic modalities (cognitive, pharmacological, and alternative). Moreover, these therapeutic strategies must be adaptive to the specific cognitive discrepancies of the patient. In general though, non-pharmacological treatment (NPT) modalities (e.g. cognitive and alternative) must be the first-line of intervention, while pharmacological therapeutics proceed after the first-line interventions fail (Zdanys, et al., 2016). And, yet, in emergency situations, the pharmacological modality must be the preferential treatment approach.
Three Therapeutic Interventions
Cognitive Behavioral Therapy as a Cognitive Intervention
The National Institute for Health and Care Excellence (NICE) categorized it into two groups, namely: the cognitive therapies, which are intended to improve cognitive symptoms and thus maintain patient functions; and the behavioral therapies, which are designed to intervene with non-cognitive symptoms and problematic behaviors (Turner, 2016). As suggested the previous subsection on the general principles of management, cognitive interventions for dementia in Alzheimer’s disease must be considered the first-line of treatment in the ordinary course of the disorder. In fact, like other NPT approaches, Zdanys, et al. (2016) indicated it as imperative in dementia BPS management considering the empirically established risks associated with medications. The NICE, however, recognizes only a single non-pharmacological therapy: the cognitive stimulation therapy (CST), which is often encouraged in group therapy format (Turner, 2016). The inherent weakness in this approach, however, was the optimal focus on cognitive stimulation in the absence of behavioral modification. Meanwhile, the UK National Health Service (NHS), however, widely endorses the cognitive-behavioral therapy (CBT), a largely psychological approach in addressing the interaction between cognition, affect, and behavior through a collaborative intervention format (Spector, et al., 2015). It has the added advantage of incorporating behavioral components in dementia therapy for elderly Alzheimer’s disease patients.
This assessment preferred the CBT approach because, unlike CST, it is more interactive design between cognition and behavior as objects of therapeutic intervention.
Validity: Current studies in CBT primarily consist of case studies, randomized controlled trials, and meta-analyses, which indicates robust findings and outcomes (Spector, et al., 2015; Sturmey, 2009) as an empirically supported modality in treating dementia in Alzheimer’s disease. Positive outcomes in depression therapy had been replicated in at least 10 RCT between 2007 and 2008 (Sturmey, 2009).
Efficacy: Orgeta, et al. (2014) suggested that, while CBT can help Alzheimer’s patients with depression and diagnosed with mild cognitive impairment (MCI), it may not be helpful at all in severe dementia. There is, however, robust evidence in its effectiveness as a first-line strategy for anxiety in elderly individuals without dementia (Spector, et al., 2015). It had shown better outcomes in the treatment of depression among elderly dementia patients.
Symptom and behavioral management: As a depression therapy in dementia disorder associated with Alzheimer’s disease, competent delivery of CBT in terms of positive behavioral outcomes, which persisted even two years thereafter (Sturmey, 2009).
Recidivism (relapse potential): Moreover, it was evidently more superior to paroxetine due to its lower relapse and recurrence rates in addition to the known pharmacotherapeutic risks involved (Sturmey, 2009).
Cognitive Enhancers as a Pharmacological Intervention
Zdanys, et al., (2016) recommended that certain medications, such as anticholinergics and psychostimulants, must be avoided altogether in treating dementia in Alzheimer’s disease. Cognitive enhancers, such as acetylcholinesterase inhibitors and memantines, are essentially considered as the first-line treatments for mild to moderate Alzheimer’s disease.
Validity: Studies on cholinesterase inhibitors, which are randomized controlled trials (RCT), and memantines, which are largely systematic reviews and meta-analyses, showed evident strong validity to back up their findings and adequate generalizability potentials.
Efficacy: Acetylcholinesterase inhibitors, such as donepezil, rivastigmine, and galantamine, showed, in three of nine studies, statistically significant increase (over placebo) in NPI scores among patients with Alzheimer’s disease (Rodda, Morgan, & Walker, 2009). Meanwhile, six studies showed modest but statistically significant progress in dementia BPS (NPI scores) with memantines (Zdanys, et al., 2016). However, replication seemed difficult to establish in more recent studies (Maidment, et al., 2008).
Symptom and behavioral management: Rivastigmine specifically showed improvements in agitation/aggression and anxiety/phobias symptom categories (Cumbo & Ligori, 2014). Both donepezil and rivastigmine increased NPI scores while improving behavioral disturbances (Zdanys, et al., 2016). Acetylcholinesterase inhibitors, however, are generally well-tolerated despite transient, mild-to-moderate adverse effects, such as increase disinhibition, impulsivity, and repetitive behaviors (Cumbo & Ligori, 2014; Mendez, 2009).
Recidivism (relapse potential): Current literature failed to indicate information on the relapse potential of dementia BPS in Alzheimer’s disease treated with these medications. In dementia associated with the presence of Lewy bodies, however, long term treatment (more than six months) with donepezil had resulted to relapses of visual hallucinations in all patients involved (Ukai, et al., 2015). There had been no available, or at least online accessible, relapse studies on rivastigmine.
Music Therapy as an Alternative Intervention
Alternative interventions are essentially the second group of non-pharmacological treatments, which has no active psychotherapeutic component, under the NICE classification (Turner, 2016). It comprised such diverse therapeutic modalities as psycho-education to sensory interventions, such as music therapy, aromatherapy, and light therapy among others (Zdanys, et al., 2016). Among the sensory modalities, music therapy appeared to have evident promise as an intervention for dementia in Alzheimer’s disease.
Validity: Larger studies in music therapy as an intervention for dementia in Alzheimer’s disease involved primarily systematic reviews of earlier studies. While these studies are adequately robust, the studies were focused on few symptoms, such as agitation.
Efficacy: Livingston, et al. (2014) noted the improvement that music therapy brought to the overall agitation among older patients with dementia. In a systematic review of eight studies, Craig (2014) found out that best results in reducing agitation were associated with familiar music in a group therapy context (facilitated by an expert music therapist) at an optimum frequency of 2 to 3 sessions weekly for 30 to 50 minutes per session.
Symptom and behavioral management: Elderly patients with dementia had been shown to still have a preserved ability to sing and their memory of song lyrics despite their language and memory deficits (Turner, 2016). It also promotes interpersonal engagement and interaction either with a psychotherapist, other individual patients, or members of a therapy group through musical instruments and human voice. Theoretically, it encourages patients with dementia in Alzheimer’s disease to express themselves verbally and non-verbally, receive cognitive stimulation, and develop listening skills. Moreover, prior musical knowledge or abilities are often unnecessary to benefit from this approach.
Active music listening, which involves interpersonal and improvisational components, was also found far stronger in efficacy than passive listening on QOL while both performed similarly in reducing agitation (Raglio, et al., 2013). Evidence, however, indicated that the complex and dynamic experience generated from listening to music can stimulate various areas in the brain that govern cognition (Clark & Warren, 2015; Belfi, Karlan, & Tranel, 2016), emotion (Juslin, Barradas, & Eerola, 2015), locomotion (Large, Herrera, & Velasco, 2015; Vandervert, 2015), and autonomic function (Vlachopoulos, et al., 2015).
Recidivism (Relapse Potential): There had been no apparent evidence so far on the relapse potential of dementia in patients with Alzheimer’s disease after the discontinuation of music therapy.
Conclusion
The growing interest in dementia research had contributed significantly to the surge of evidence-based therapeutic modalities with significant potentials in managing the disorder in the context of Alzheimer’s disease. There are exciting prospects in the further investigation of CBT and music therapy as primary therapeutic interventions, alone or together, for dementia in Alzheimer’s disease due to indications of greater efficacy over the pharmacological approaches in relation to certain symptoms perhaps even in more severe dementia. Its therapeutic mechanism, however, is longer than that of the pharmacological interventions, which remained crucial in emergency situations. Until more comprehensive evidence becomes available in favor of non-pharmacological interventions for dementia, clinical practitioners, including psychiatrists and psychotherapists, may have to continue with the standard multi-modal approach accessible to their respective specialties, in managing dementia in patients with Alzheimer’s disease.
References
Alzheimer’s Association. (2016). 2016 Alzheimer’s disease facts and figures. Chicago, IL: Alzheimer’s Association/National Office. (Alzheimer’s Association, 2016)
Banerjee, S., Hellier, J., Romeo R., Dewey, M., Knapp, M., et al., (2013). Study on the use of antidepressants for depression in dementia: the HTA-SADD trial – a multicenter, randomized, double-blind, placebo-controlled trial of the clinical effectiveness and cost-effectiveness of sertraline and mirtazapine. Health Technology Assessments, 17(7), 1-166.
Belfi, A.M., Karlan, B., & Tranel, D. (2016, August 24). Music evokes vivid autobiographical memories. Memory, 24(7), 979-989.
Brodaty, H. & Bums, K. (2012). Nonpharmacological management of apathy in dementia: A systematic review. American Journal of Geriatric Psychiatry, 20(7), 549-564.
Clark, C.N. & Warren, J.D. (2015). Music, memory and mechanisms in Alzheimer’s disease. Brain, 138(Pt 8), 2122-2125.
Craig, J. (2014). Music therapy to reduce agitation in dementia. Nursing Times, 110(32-33), 12-15.
Cumbo, E. & Ligori, L.D. (2014). Differential effects of current specific treatments on behavioral and psychological symptoms in patients with Alzheimer’s disease: A 12-month, randomized, open-label trial. Journal of Alzheimer’s Disease, 39(3), 447-485.
Juslin, P.N., Barradas, G., & Eerola, T. (2015). From sound to significance: Exploring the mechanisms underlying emotional reactions to music. American Journal of Psychology, 128(3), 281-304.
Large, E.W., Herrera, J.A., & Velasco, M.J. (2015). Neural networks for beat perception in musical rhythm. Frontal System Neuroscience, 9(1), 159.
Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., et al. (2015). A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological, and behavioral interventions for managing agitation in older adults with dementia. Health Technology Assessment, 18(39), 1-226, v-vi.
Maidment, I.D., Fox, C.G., Boustani, M., Rodriguez, J., Brown, R.C., & Katona, C.L. (2008). Efficacy of memantine on behavioral and psychological symptoms related to dementia: A systematic meta-analysis. Annals of Pharmacotherapy, 42(2), 31-32.
Mendez, M.F. (2009). Frontotemporal dementia: Therapeutic interventions. Frontotemporal Neurological Neuroscience, 24(1), 168-178.
Orgeta, V., Qazi, A., Spector, A.E., & Orrell, M. (2014). Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database Systematic Review, 1(1), CD009125.
Raglio, A., Bellandi, D., Baiardi, P., Gianotti, M., Ubezio, M.C. & Granieri, E. (2013). Listening to music and active music therapy in behavioral disturbances in dementia: A crossover study. Journal of the American Geriatrics Society, 61(4), 645-647. (Raglio, et al., 2013)
Rodda, J., Morgan, S., & Walker, Z. (2009). Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine, and galantamine. International Psychogeriatrics, 21(5), 513-524.
Scrutton, J. & Brancati, C.U. (2016, April). Dementia and comorbidities: Ensuring parity of care. London, England: International Longevity Center-UK. (Scrutton & Brancati, 2016)
Spector, A., Charlesworth, G., King, M., Lattimer, M., Sadek, S., et al. (2015). Cognitive-behavioral therapy for anxiety in dementia: Pilot randomized control trial. The British Journal of Psychiatry, 206(1), 509-516. (Spector, et al., 2015)
Steffens, D.C. (2008). Separating mood disturbance from mild cognitive impairment in geriatric depression. International Review of Psychiatry, 20(4), 374-381.
Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33(6), 818-829.
Tampi, R., Williamson, D., Muralee, S., Mittal, V., McEnerney, N., Thomas, J., et al., (2011). Behavioral and psychological symptoms of dementia: Part 1 – Epidemiology, heritability, and evaluation. Clinical Geriatrics, 19(5), 41-46.
Turner, T. (2016, June 21). Dementia care: An overview of available non-pharmacological therapies. The Pharmaceutical Journal.com. Retrieved from: http://www.pharmaceutical-journal.com/learning/learning-article/dementia-care-an-overview-of-available-non-pharmacological-therapies/20201270.article.
Ukai, K., Fujishiro, H., Iritani, S., & Ozaki, N. (2015, June). Long-term efficacy of donepezil for relapse of visual hallucinations with dementia with Lewy bodies. Psychogeriatrics, 15(2), 133-137.
Vandervert, L. (2015). How music training enhances working memory: A cerebrocerebellar blending mechanism that can lead equally to scientific discovery and therapeutic efficacy in neurological disorders. Cerebellum Ataxias, 2(1), 11.
Vlachopoulos, C., Aggelakas, A., Ioakeimidis, N., Xaplanteris, P., Terentes-Printzios, D., et al. (2015). Music decreases aortic stiffness and wave reflections. Atherosclerosis, 240(1), 184-189.
Zdanys, K.F., Carvalho, A.F., Tampi, R.R., & Steffens, D.C. (2016). The treatment of behavioral and psychological symptoms of dementia: Weighing benefits and risks. Current Alzheimer Research, 13(1), 1124-1133. (Zdanys, et al., 2016)
