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Podium Presentations: Sunday, July 16, 2017
S1-02-04
NEURODEGENERATIVE PATHOBIOLOGY
IN PRECLINICAL MODELS OF
REPETITIVE MILD TRAUMATIC BRAIN
INJURY
Fiona Crawford, Roskamp Institute, Sarasota, FL, USA.
Contact e-mail: fcrawford@rfdn.org
P171
intervention reduced cost compared to treatment as usual, and the benefits achieved were therefore associated with a cost saving.
Conclusions: This is the largest RCT of a non-pharmacological intervention for people with dementia in nursing homes. WHELD
conferred improvements in agitation and in quality of life amongst individuals with agitation, over 9 months and reduced cost. WHELD
therefore has a number of advantages compared to pharmacological
treatments currently used to treat agitation.
Abstract not available.
SUNDAY, JULY 16, 2017
FEATURED RESEARCH SESSION
F1-01
ECOPSYCHOSOCIAL TREATMENT OF ALZHEIMER?S DISEASE
AND RELATED DEMENTIAS: CURRENT ADVANCES
F1-01-01
IMPACT OF WHELD INTERVENTION ON
NEUROPSYCHIATRIC SYMPTOMS,
ANTIPSYCHOTIC USE AND QUALITY OF
LIFE IN PEOPLE WITH DEMENTIA
LIVING IN NURSING HOMES: A CLUSTERRANDOMIZED TRIAL
Clive Ballard1, Jane Fossey2, Anne Corbett1, Martin Orrell3,
Renee Romeo4, Esme Moniz-Cook5, Bob Woods6, Rhiannon Whitaker7,
1
University of Exeter Medical School, Exeter, United Kingdom; 2Oxford
Health NHS Trust, Oxford, United Kingdom; 3Institute of Mental Health,
Faculty of Medicine & Health Sciences, University of Nottingham,
Nottingham, United Kingdom; 4King?s College London, London, United
Kingdom; 5Institute of Rehabilitation, Dementia Applied Research Centre,
University of Hull, Hull, United Kingdom; 6Institute of Medical and Social
Care Research, Bangor University, Bangor, United Kingdom; 7Whitaker
Research Ltd, Bangor, United Kingdom. Contact e-mail: c.ballard@exeter.
ac.uk
Background: Agitation is a common and distressing symptom
affecting large numbers of people with dementia and impacting
significantly on quality of life. In the absence of safe, effective pharmacological therapies there is a need for evidence-based, cost-effective first-line non-drug treatments. A factorial study has enabled us
to optimize the intervention, which we have now evaluated in a large
cluster RCT. Methods: Design: A randomized controlled cluster trial
comparing the WHELD intervention with treatment as usual in 69
UK nursing homes Participants: Nursing home residents with dementia Intervention: All nursing homes receiving the WHELD intervention received staff training in person-centered care (PCC), social
interaction (SoI) and antipsychotic review (AR) followed by ongoing
delivery through a care staff champion model. Main Outcome Measures: Quality of life (DEMQOL-proxy), agitation (Cohen Mansfield
Agitation Inventory), neuropsychiatric symptoms (NPI), antipsychotic
use and pain (Abbey Pain Scale). Results: Are presented as weight
mean difference in change with 95% Confidence Intervals (CI). Intervention costs were calculated using published cost function figures
and compared with usual costs. Results: 971 people were randomized
to WHELD or treatment as usual. WHELD conferred a significant
improvement in agitation (CMAI 8.63 95% CI 1.06 to 16.19,
p�025). There was also a numerical non-significant benefit in quality of life (DEMQOL proxy 10.93 95% CI -2.82 to 24.68, p�12),
which became significant in people with agitation (DEMQOL proxy
16.56 95% CI 0.35-32.78, p�045). An exploratory analysis showed
benefit in the participants with moderate or severe pain at baseline
(Abbey Pain Scale 2.93 95% CI -2.46 -.49, p�003). Antipsychotic
drug prescribing was stable in both treatment groups. The WHELD
F1-01-02
THE IMPACT OF ENVIRONMENTAL
FACTORS ON ENGAGEMENT AND MOOD
OF PERSONS WITH DEMENTIA
ATTENDING RECREATIONAL GROUPS
Jiska Cohen-Mansfield, School of Public Health, Sackler Faculty of
Medicine, Tel Aviv University, Tel Aviv, Israel. Contact e-mail: jiska@post.
tau.ac.il
Background: Nonpharmacological interventions aim to address the
needs of persons with dementia thereby improving their quality
of life and preventing or reducing behavioral symptoms. Such
needs include social contact and engagement with meaningful activities. Because prior research has shown that social activities
are the most engaging for persons with dementia, we studied the
impact of group activities in this population. In this study, we examined the impact of group topic and environmental factors on
engagement and mood of persons attending recreational groups.
Methods: Participants were 69 nursing home residents with dementia with an average score of 4.19 on the Cognitive Performance
Scale (1糹ntact and 6約everely impaired). All were invited to
two rounds of ten activity topics (e.g., singing) in their units. Therapeutic recreation staff members who ran the groups and research
observers independently rated participants? level of engagement,
active participation, attitude towards the activity and positive
mood during group activities and non-group control conditions.
Additionally, the time of day during which group activities were
held and the groups? sizes were recorded, and temperature, light,
and noise were rated. Background variables and level of cognitive
function were taken from the MDS-2 in participants? health record.
Results: Significantly higher ratings of participants? engagement and
positive mood were observed during group activities than during the
control observations ? according to both research and therapeutic recreation staff (all p<.001). Cognitive functioning was significantly
related to all outcome variables and served as a covariate in all analyses
of environmental factors (p<.001). Group content was a significant
predictor of all outcome variables (p<.001). Loud background noise
and small group size were associated with significantly worse outcomes in some of the analyses (p ranging between ns to p<.001). Conclusions: The results support the importance of groups for persons with
dementia. They also highlight the role of some environmental factors
(e.g., designing space that would minimize external noise) in optimizing group activities for this population. Such groups should
form a basis for nonpharmacological interventions for persons with
dementia.
F1-01-03
CREATING PERSON-CENTERED
ENVIRONMENTS AS TREATMENT FOR
DEMENTIA
Cameron Camp, Center for Applied Research in Dementia,
Solon, OH, USA. Contact e-mail: cameron@cen4ard.com
Background: Person-centered care for dementia faces challenges in
its tranlsation into actual practice, including: 1) assessment that
P172
Podium Presentations: Sunday, July 16, 2017
Table 1
Montessori Assessment System (MAS) Psychometric Properties
Reliability
The Cronbach alpha coefficient for the MAS � (a � 0.85).
The item-total correlations for the 8 subscales of the MAS ranged from
0.62 to 0.94, with a mean of 0.79.
Principal component analysis
There were no outliers and no apparent problems with restriction of range.
Bartlett test of sphericity (c2 �35.8; df 28; p < 0.001) and KaiserMeyer-Olkin measure of sampling adequacy (0.90) indicate MAS data
matrix is very well suited to principal component analysis. One unique
principal component that explained 66.7% of score variance was found
with factor loadings
Ranging from 0.66 to 0.92, with a mean of 0.81.
Convergent validity
MAS total score correlation with the Mini-Mental Status Examination
(MMSE) (r � 0.67); with the Severe Impairment Battery (SIB-S)(r �
0.81)
Discriminant validity
MAS total score with age (r � 0.04); length of institutionalization (r �
0.07); education (r � 0.16). gender (t � -0.87, p � 0.38). No significant
effects.
Test-retest reliability
N � 72; 15-day interval; r � 0.90
Inter-rater reliability
N � 53; The intra-class correlation coefficient for inter-rater reliability �
0.95
emphasizes detection of deficits, and 2) responsive behaviors that
subsume extensive time and attention of caregivers. Methods: Using
Montessori-based activities for strength-based assessment of persons with dementia has been documented as a means of creating
Table 2
Percent (%) reduction in use of medications wandering, agitation, and
employee turnover before (1 year) and after (1 year) of Memory in Rhythm
(MIR) program in memory units of Skilled Nursing Facilities (SNFs) and
Assisted Living (AL) residences in the United States
Medication
Type
Fmployee
#Residents
Center
Anti- AntiPsyc Anx
AntiDep Hypnotics Wandering Agitation Turnover
SNF1
SNF2
SNF3
SNF4
SNF5
SNF6
SNF7
SNF8
SNF9
Average
ALI
AL2
AL3
AL4
AL5
AL6
AL7
Average
78
75
76
78
46
56
30
50
55
60
60
58
20
60
60
60
42
53
42
40
32
41
21
32
15
35
30
32
40
35
15
41
45
46
60
40
79
76
72
73
42
51
25
48
50
57
55
55
20
58
59
60
65
53
100
100
100
100
90
89
70
95
100
94
100
100
90
100
100
100
100
98
Anti-Psyc, antipsychotic medication;
Anti-Anx, antianxiety medication;
Anti-Dep, antidepressant medication
85
85
87
79
86
75
72
88
89
83
75
95
85
87
90
91
87
87
85
85
89
86
88
76
73
90
90
85
80
95
85
90
90
92
90
89
31
31
15
10
15
15
15
20
42
22
15
12
12
15
15
15
15
14
12
14
60
12
20
12
24
10
12
12
10
8
30
15
15
15
Table 3
Percent (%) increase of residents showing weight gain, residents who began
sleeping at night, and % census ? number of residents in the memory unit increase; eating (# of residents regaining ability to feed themselves), and
ADLs (# of residents who regained/improved one ADL), in the year after the
Memory in Rhythm (MIR) program in comparison with the prior year in
memory units of Skilled Nursing Facilities (SNFs) and Assisted Living (AL)
residences in the U.S
Center
Weight
Gain
Sleeping
Census
Eating
ADIs
#Residents
SNF1
SNF2
SNF3
SNF4
SNF5
SNF6
SNF7
SNF8
SNF9
Average
AL1
AL2
AL3
AL4
AL5
AL6
AL7
Average
100
100
99
95
96
81
80
95
85
92
89
98
90
92
95
97
92
93
90
90
97
95
89
82
80
92
90
89
80
98
85
90
95
98
85
90
20
20
26
29
15
15
15
25
14
20
25
67
75
15
10
10
87
41
2
3
8
2
4
2
6
1
2
3
2
0
1
4
2
2
2
2
12
7
36
8
10
2
12
5
8
11
6
10
6
15
8
12
8
9
12
14
60
12
20
12
24
10
12
12
10
8
30
15
15
15
person-centered plans of care based on remaining capacities of persons with dementia. Recent research in France has extended this
work by development of the Montessori Assessment System
(MAS). 196 long-term care residents in France with moderate to severe dementia were assessed with the MAS, the MMSE and the Severe Impairment Battery ? short form (SIB-S). In a second study,
residents in dementia care units (9 skilled nursing facilities
[SNFs] and 7 assisted living residences [ALs] in the U.S.;
N�1) exhibiting responsive behaviors which were disruptive
and consuming large amounts of staff members? time and energy
were put into groups with full-day programming ? Memory in
Rhythm (MIR). MIR uses Montessori-based, person-centered approaches to care. Data were collected and compared for the year
previous to MIR implementation and for the year after MIR implementation. Results: As shown in Table 1, the MAS has excellent psychometric properties, including test-retest (r � 0.90) and inter-rater
reliability (0.95), internal consistency (a � 0.85), as well as good
convergent and divergent validity. In addition, residents with dementia generally responded favorably to the assessment experience, while the MAS yielded information which immediately
could be translated into person-centered plans of care. In the
U.S., multi-residence study, as shown in Table 2, implementation
of MIR was associated with the following average reductions:
anti-psychotic medication use (SNFs�%; ALs�%), hypnotics
(SNFs�%; ALs�%), staff turnover (SNFs�%;
ALs�%), wandering (SNFs�%; ALs�%), and agitation
(SNFs�%; ALs�%), with increases in weight (SNFs�%;
ALs�%), sleeping at night (SNFs�%; ALs�%), and
census (SNFs�%; ALs�%), as shown in Table 3. Conclusions:
Assessing capacities of persons with dementia, especially those in
moderate to advanced stages, is both practical and feasible. Translating this information into programming making use of such
Podium Presentations: Sunday, July 16, 2017
information, and targeting residents with highly disruptive responsive behaviors results in desirable outcomes for residents, caregivers, and administrators.
F1-01-04
COMPREHENSIVE, INDIVIDUALIZED,
PERSON-CENTERED MANAGEMENT
PROGRAM IN SUBJECTS TREATED WITH
MEMANTINE ENHANCES FUNCTIONING
BY 750%, IN COMPARISON WITH
MEMANTINE TREATMENT ALONE, IN
PERSONS WITH MODERATE-TO-SEVERE
AD IN 28-WEEK RANDOMIZED
CONTROLLED TRIALS
Sunnie Kenowsky1,2, Isabel Monteiro1,2,3, Carol Torossian1,2,3,
Sloane Heller1,2, Zabeen Noorani1,2, Yongzhao Shao1,3, Barry Reisberg2,3,
1
New York University School of Medicine, New York, NY, USA; 2New York
University Langone Medical Center, New York, NY, USA; 3New York
University Alzheimer?s Disease Center, NYU Langone Medical Center, New
York, NY, USA. Contact e-mail: sunnie.kenowsky@nyumc.org
Background: Memantine was approved as the first treatment for
moderate-to-severe AD following a pivotal trial conducted by
Reisberg et al. (N Engl J Med., 2003) and other supportive
studies. The development of approved treatments that were
not curative accentuated the continuing care needs of these
AD persons. Therefore we conducted a 28-week randomized
controlled trial in which subjects (N�) were randomly assigned to usual community care (UCC) plus memantine treatment, or to a comprehensive, individualized, person-centered
management program (CI-PCM) (developed by S.K.), plus
P173
memantine treatment (Reisberg, et al., Dement Ger Cog Disord.,
2017; 43: 100-117). Significant improvement in the Functional
Assessment Staging measure (FAST) (Sclan & Reisberg, Int
Psychogeriatr, 1992), was observed at all post-baseline observation periods (p<0.01 at week 28). Herein, we examined the
magnitude of functional benefit on the FAST with the CIPCM program in comparison with the magnitude of benefit
with memantine treatment alone. Methods: We employed the
FAST scoring methodology of the 2003 NEJM trial, termed the
FAST disability score (FAST-DS) (see Table 1). We then compared
the FAST-DS score magnitude of improvement in the memantine +
CI-PCM program, versus the memantine + UCC; with the magnitude of FAST-DS improvement in the 2003 pivotal trial results of
memantine versus placebo treatment (see Table 1). Results: The
mean difference between the CI-PCM + memantine intervention and the UCC + memantine comparator group FAST-DS
score is 3. The mean difference between the memantine treatment versus placebo in the 2003 trial FAST-DS scores is 0.4.
Therefore, the CI-PCM program enhanced functioning 7.5
times over memantine treatment alone. Conclusions: A 750%
greater improvement in functioning was observed in the CI-PCM
program over memantine treatment alone. This enormous effect
of the CI-PCM program is consonant with our prior observation
of the effects of the CI-PCM program on a global measure of cognition, functioning and behavior, which was approximately 10x that
observed in the NEJM memantine trial. We attribute the CI-PCM
program success primarily to the participant caregivers learning
to memory coach the AD persons to bathe, dress, feed and toilet
themselves, to become/maintain urinary and fecal continence,
and to speak.
Table 1
Functional Assessment Staging Disability Score (FAST-DS)a Comparisons at Week 28: (1) of a Comprehensive, Individualized, Person-Centered Management
(CI-PCM) Programb Plus Memantine Treatment versus Usual Community Care (UCC)c Plus Memantine Treatment (Reisberg, et al., Dement Ger Cog Disord.,
2017); (2) with the Memantine Treatment versus Placebo Pivotal Trial (Reisberg, et al., N Eng J Med., 2003)
CI-PCM + memantine Intervention Groupb CI-PCM study
UCC + memantine Comparator Groupc CI-PCM study
Memantine Treatment Group, 2003 NEJM Memantine Study
Control Group, 2003 NEJM Memantine Study
FAST-DS scorea at
Baseline (Mean)
Observed Casesy Analysis
of Change in mean
FAST-DS score from
Baseline at Week 28
Mean FAST-DS score
difference between
Treatment Arms at
Week 28
4 (n�)
4 (n�)
2.8d (n�6)
2.8d (n�6)
-2 (n�)
1 (n�)
0.1d (n�)
0.5d (n�)
3
0.4
a
The FAST-DS scores were calculated as: FAST stage (Sclan, S.G., & Reisberg, B., Int Psychogeriatr, 1992) 4 � FAST- DS score of-1, FAST stage 5 � FASTDS score of 0, FAST stage 6a � FAST-DS score of 1, FAST stage 6b � FAST-DS score of 2, FAST stage 6c � FAST-DS score of 3, FAST stage 6d � FAST-DS
score of 4, FAST stage 6e � FAST-DS score of 5, FAST stage 7a � FAST-DS score of 6, FAST stage 7b � FAST-DS score of 7, FAST stage 7c � FAST-DS score
of 8, FAST stage 7d � FAST-DS score of 9, FAST stage 7e � FAST-DS score of 10 and FAST stage 7f � FAST-DS score of 11; in the same manner as the 2003
pivotal trial (Reisberg, et al., N Eng J Med.).
b
The CI-PCM program consisted of: a caregiver course in Alzheimer?s care, management assessment, therapeutic residential visits and carer support group
meetings (Reisberg, et al., Dement Ger Cog Disord., 2017).
c
UCC, Usual Community Care. UCC participants had their questions answered and were referred to the local chapter of the Alzheimer?s Association and
other community resources when appropriate for day care center and support group programs, caregiver training, care counseling, and safe return/medic
alert bracelets by the study Alzheimer?s care specialist (S.K.) or New York University Alzheimer?s Disease Center clinicians and social workers. UCC
participants received in total USD 100 compensation upon completion of the week 28 study visit which is unlikely to have had any meaningful clinical
effect.
The UCC Comparator Group in the CI-PCM study may appear different from the memantine treatment and placebo groups in the 2003 NEJM study on the
FAST-DS assessment. However, the sample sizes of the memantine treatment and placebo groups in the 2003 NEJM study were much larger than the sample size
of the UCC comparator group in the current CI-PCM study. Therefore, the differences in the UCC CI-PCM study comparator group FAST-DS results are not
significantly different from the 2003 memantine treatment or placebo FAST-DS scores.
d
From Table 2, Reisberg, et al., N Engl J Med., 2003.
y
Observed cases are the completers of the 28-week CI-PCM study or of the 28-week NEJM trial.
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