1. Dementia and Rehabilitation
Maria Crotty FAFRM
Professor of Rehabilitation and Aged Care
Repatriation General Hospital
Flinders University

2. The NHMRC Partnership Centre for Dealing with Cognitive Decline and Related Functional Decline in Older People

3. Declarations Contents here
Eli Lily – funding to Repatriation General Hospital 2012 for trial of drug treatment for sarcopenia (muscle weakness)
Novartis – funding for a trial of a drug treatment for sarcopenia 2016

4. After a diagnosis of dementia staying fit may not be supported by our social context
Many people (including older people themselves) view older age as a time of inactivity
Dementia is a feared condition and hence kept hidden and avoided
Australian hospitals and private health fund programs are not very dementia friendly.
Community gyms often aren’t suitable

5. Biological perspectives
Dementia is a disease that makes disengagement easy
Insight and self awareness of deficits
Executive dysfunction and behavioural inertia
Dementia gets worse and leads to disability and death
Long disease trajectory with variable rates of deterioration

6. Rehabilitation - Functional Reserve
Clegg et al. Frailty in Elderly People. Lancet Feb

7. What do the new guidelines say about rehabilitation?
Review the available evidence
Creates recommendations ( in this case starting with the NICE 2006)
Rates these recommendations
Practice points: No better evidence other than consensus expert opinion
Consensus based recommendations: Only poor quality evidence exists
Evidence based recommendations: Adequate quality evidence to be reviewed and this evidence is rated

8. Clinical Practice Guidelines and Principles of care for people with dementia
Launched March 2016
Included consumers and dementia “experts” from around Australia and across disciplines. Updated the literature from 2006 to 2015
109 recommendations
29 evidenced based recommendations
most of evidence was low quality
Similar to other conditions such as Diabetes although the number of low quality EBR is higher.
Endorsed by a range of specialist societies
Consumer version will be launched in Canberra NOVEMBER 2016

9. Summary of recommendations
Best level of evidence existed for
Avoiding and appropriate use of antipsychotics
Avoiding antidepressants for depressive symptoms
Antidepressants for agitation
Numerous other recommendations
Non drug treatment for Changed Behaviours of Dementia
Carer training and support programs
Accessing assessment and diagnostic services

10. Promoting functional independence
Encourage “dyadic” interventions including environmental assessment and modification, problem solving and carer training.
Encourage exercise

11. Limitations of the NHMRC Guideline
Clinical guidelines are a snapshot in time
Evidence is constantly evolving
The process is very structured with close monitoring about the relationship between the recommendation and evidence
The guideline didn’t deal well with
Cognitive stimulation, training and rehabilitation
Technological innovations with dementia
Combined exercise and cognitive training
Chris Hatherley

12. The effect of different treatment approaches on activities of daily living function in people with dementia.
The effect of different treatment approaches on activities of daily living function in people with dementia.
In a recent review comparing non-pharmacological and pharmacological effects on activities of daily living in people with dementia, exercise had a large magnitude of effect compared to pharmacological interventions, however, the quality of evidence was deemed to be low.
Laver K, Dyer S, Whitehead C, Clemson L & Crotty M. BMJ Open 2016;6:e010767
©2016 by British Medical Journal Publishing Group

13. Dyadic interventions – key aspects
Observe the home environment
Evaluate capabilities and family concerns
Involve the person with dementia and family members
Introduce small, incremental changes
Use role play or demonstration to support skill building
Readjust strategies as needed
Aim for activities which engage

14. Why COPE? Aimed at people with mild to moderate cognitive impairment
Demonstrated to be effective in a large high quality RCT in the US
Increases patient engagement
Delays functional decline improves carer wellbeing
Positive effects reported even 9 months after intervention
Why COPE?
Care of Persons with Dementia in their Environments (COPE)
Assessment phase
Treatment
Identifying and addressing three main concerns, one at a time
For each area, brainstorm together possible strategies
Narrow these (highlight/prescribe) to the strategies that are acceptable to the carer
Use of ‘prescriptions’ to supplement therapist advice
Training the carer in key skills – communication, coping, activity engagement, generalising
Environment
Avoid overstimulation
Reduce hazards
Cosy, meaningful environment with positive reinforcement and simple familiar items

15. Translational pipeline
Development
Discovery
Feasibility
Proof of concept
Evaluation
Efficacy
Effectiveness
Implementation
Translation/Implementation
Dissemination, diffusion, scaling up

16. Exercise and Dementia
Pharmacological interventions for people with dementia (e.g., antipsychotics, cholinesterase inhibitors) have limited effectiveness in reducing cognitive and functional decline and can have many adverse effects.
Exercise has been identified as a potential intervention strategy which has been explored in relation to improving the symptoms of dementia or slowing down the progression of dementia.
Previous RCTs examining aerobic exercise interventions in cognitively healthy older adults or adults with moderate cognitive impairment, but not dementia, have suggested some improvements of cognitive function across different cognitive domains (Angevaren 2008, Tseng 2011), but larger studies are needed to validate these findings (Young, 2015). These RCTs have usually focused on 60-minute exercise programs scheduled 3 times per week and people were followed up over 24 weeks. However, it remains unclear if simple one-component exercise programs or multicomponent exercise programs are more beneficial for cognitive function in older adults.
A recent study in rats suggested sustained aerobic exercise, such as running, has positive effects on brain structure and function and therefore could offer protective effects towards cognitive function (Nokia, 2016).
Current guidelines suggest older adults, over 65 years old, complete 30 minutes of moderate exercise on most days.

17. How exercise may benefit people with dementia
Improvements of:
Cognitive function
Activities of Daily Living
Well-being
Social interaction
Preservation of neuronal structure
Insulin signalling pathways
Exercise for people with dementia
Vascular health
Exercise interventions are being investigated in relation to cognitive health as exercise may improve vascular health, such as by reducing blood pressure, oxidative stress and levels of inflammation which are all implicated in the pathophysiology of dementia. In addition, exercise may improve insulin sensitivity which may reduce the formation amyloid-β plaques, a classic hallmark of Alzheimer’s disease, and exercise may also induce preservation of neuronal structure. Exercise programs may also encourage a socialization aspect which has also been associated with improved cognitive function.

18. Prevention of Dementia
Lots of observational evidence that ongoing physical activity from mid life reduces the risk of dementia
In normal older adults cognition improves with exercise
Some RCT evidence once you have Mild Cognitive impairment that the rate of cognitive loss slows but trials are inconsistent
Areas of increased brain activation after training in the MCI group: activated clusters (Post-training > Pre-training 2) for both memory encoding and retrieval (P < 0.001; >10 voxels). A scatter plot with fit line shows the significant correlations in subjects with MCI between their memory performances at post-training and the β-values for the encoding condition at post-training in the right inferior parietal lobule.
© The Author (2011)

19. Evidence on exercise after diagnosis isn’t as clear
The vascular effects of aerobically based exercise training are well documented however the impact of aerobic exercise on cognition after diagnosis has not been unequivocally established
Multimodality exercise programs with mind motor training are now a focus – visuospatial outcomes
Holistic frailty approaches have growing evidence
Gregory M. Group based exercise and cognitive physical training in older adults with self reported cognitive complaints: the multiple-modality, Min-Motor (M4) study protocol. BMC Geriatrics 2016

20. Frailty and dementia
Postulated that frailty and dementia share common underlying mechanisms:
Cardiovascular and cerebrovascular disease are risk factors for both frailty and AD
Raised levels of pro-inflammatory cytokines eg. interleukins, CRP, TNF-α common to both, indicating possible state of low grade chronic inflammation
Mitochondrial malfunction
Oxidative stress
Association between pre-frailty status and cognitive impairment gives opportunity for preventative interventions with the combined aim of preventing the onset of frailty and slowing cognitive decline
Raji 2010; Watson 2010; Zuliani 2007

21. Recommendations for management of frailty in dementia
Aerobic exercise:
Some suggestion increases hippocampal size
Slows cognitive decline and improves function in people with mod-severe dementia
Is feasible in nursing home residents with dementia
Resistance/strength training:
Lowers interleukins and TNF-α
Improves cognitive function (in older people without cognitive impairment)
Cassilhas 2007; Littbrand 2006; Venturelli 2011

22. Rehabilitating frailty in a community setting is more than exercise
Frailty: components of a multifaceted interdisciplinary intervention
Exercise
Nutrition
Geriatric Evaluation and Management approach
Environment factors – family / carers / services / equipment
Personal factors - adherence
Fairhall et al. BMC Medicine 2011;9:83

23. After 12 months:
frailty reduction (number needed to treat 7)
mobility improved (moderate effect size)
for people with greater frailty, intervention “dominant” on health economic analysis

24. Rehabilitation for people who live in nursing homes
Few trials. Gains in functioning possible but may need different delivery approach.
May require a longer length of program to achieve equivalent gains.
Pain is a key issue
“Return on investment” is uncertain.

25. Conclusion
Rehabilitation Models for Dementia are emerging but lots of gaps
Different populations so different delivery models at various time points
Ripe for “disruptive innovation”