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BMJ. Dec 9, 2006; 333(7580): 1184–1185.
PMCID: PMC1693638

Treatment of dementia in the community

Jeannette Golden, senior registrar in old age psychiatry and Brian Lawlor, Conolly Norman professor of old age psychiatry

Occupational therapy improves function and reduces the burden on care givers

The paper by Graff and colleagues in this week's BMJ comes at a time of disappointment and confusion for people with dementia and for those who care for them.1 The National Institute for Health and Clinical Excellence (NICE) recently recommended that cholinesterase inhibitors should not be used in patients with mild dementia, on the grounds that the modest benefits of treatment do not justify the healthcare costs.2 The hope that atypical antipsychotic drugs might play an important role in the management of non-cognitive aspects of dementia has been thwarted by evidence of adverse cerebrovascular events and increased mortality.3 Against this background, Graff and colleagues' study provides hope for effective non-pharmacological interventions and an example of how to design research into care for dementia.

The trial participants comprised 135 people with mild to moderate dementia who were living in the community. It found that a five week occupational therapy intervention (about 18 hours for each patient and care giver) significantly increased the functioning of the patient and reduced the burden on the care giver. The number needed to treat to produce a clinically significant improvement in patients' function and burden to care givers at six weeks was impressively low. For patients' daily functioning, the number needed to treat was 1.3 (95% confidence interval 1.2 to 1.4) when the assessment of motor and process skills scale was used, and 1.5 (1.4 to 1.6) if the interview of deterioration in daily activities in dementia scale was used. For burden on care givers, as assessed by the sense of competence questionnaire, the number needed to treat was 2.5 (2.3 to 2.7). Furthermore, the benefits were maintained at three months.

The trial is noteworthy in three respects—the choice of the target population, the type of intervention, and the definition of treatment outcome. The target population comprised people living with dementia and their carers. Most people with dementia live in the community and have mild to moderate disease. Almost all have a primary care giver. The care giver's role is crucial, as the daily functioning of people with dementia depends on the quality of care received at home.4 The quality of the relationship with the care giver is an important predictor of whether someone with dementia will stay in the community or enter an institution.5 By focusing the intervention on both the patient and their carer, Graff and colleagues have looked at this crucial relationship in the community setting.

The intervention comprised a personalised programme in which patients and care givers learnt to choose and prioritise meaningful activities they wanted to improve. The therapist then helped them develop optimisation and compensation strategies that effectively used their skills and personal and environmental resources. Thus, the intervention was not just tailored to the circumstances of the patient and their carer but also to their values and aspirations.

The methodology reflects the integrated approach adopted by occupational therapists supporting people with dementia and their carers. The trial justifies such an approach and points to how it can be optimised. This “selection optimisation compensation” model can identify strategies associated with healthy ageing in the population.6 7 The current study shows that this approach can also be used to develop effective interventions to help people adapt to the demands of dementia, despite their limited learning abilities.

The study end points focused on patient function and the wellbeing of care givers. People with dementia and their care givers will recognise these end points as valid. The association of these outcomes with the risk of entering institutional care makes them important for appraising the impact of the intervention on healthcare costs. The trial shows that the primary focus of research should be the patient and their carer, and that interventions and outcomes must reflect this.

Importantly the patients in the study were already stable on cholinesterase inhibitors at the outset. The benefits of the intervention are therefore in addition to those of medication. It would be interesting to assess the effect of the intervention in the absence of cholinesterase inhibitors or to compare it with a cholinesterase inhibitor in a head to head trial.

Non-pharmacological interventions in dementia have a long history, but until recently they have not been tested in high-quality controlled trials.8 This is unfortunate because interventions such as the one described by Graff and colleagues have the potential to deliver additional benefits to those obtained with drugs alone, as they encompass the patient, their carer, and their environment.

The promising results of this study need to be replicated, and further trials need to be refined and extended. This requires building research capacity and increasing resources and funding to the multidisciplinary teams that deliver care for dementia in the community. To achieve this goal, however, we need to deal with the complex factors that have caused non-pharmacological research into dementia to lag so far behind its pharmacological counterpart. We also need to examine the structure and funding of research to bring it closer to the Alzheimer's Society's vision of a proportionate balance between cause, care, and cure.9

Notes

Competing interests: BL has received honorariums and hospitality from drug companies that market cholinesterase inhibitors.

References

1. Graff MJL, Vernooij-Dassen MJM, Thijssen M, Dekker J, Hoefnagels WHL, Olde-Rikkert MGM. Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. BMJ 2006. doi: 10.1136/bmj.39001.688843.BE [PMC free article] [PubMed]
2. National Institute for Health and Clinical Excellence. Donepezil, galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer's disease. Technology appraisal TA 111. London: NICE, 2006. www.nice.org.uk/guidance/TA111.
3. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry 2006;14:191-210. [PubMed]
4. Graff MJL, Vernooij-Dassen MJM, Zajec J, Olde-Rikkert MGM, Hoefnagels WHL, Dekker J. How can occupational therapy improve the daily performance and communication of an older patient with dementia and his primary caregiver? A case study. Dementia 2006;5:503-32.
5. Spruytte N, Van Audenhove C, Lammertyn F. Predictors of institutionalization of cognitively-impaired elderly cared for by their relatives. Int J Geriatr Psychiatry 2001;16:1119-28. [PubMed]
6. Freund AM, Baltes PB. Life-management strategies of selection, optimization, and compensation: measurement by self-report and construct validity. J Pers Soc Psychol 2002;82:642-62. [PubMed]
7. Jopp D, Smith J. Resources and life-management strategies as determinants of successful aging: on the protective effect of selection, optimization, and compensation. Psychol Aging 2006;21:253-65. [PubMed]
8. Ayalon L, Gum AM, Feliciano L, Arean PA. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Arch Intern Med 2006;166:2182-8. [PubMed]
9. Alzheimer's Society. Quality research in dementia. London: AS, 2005. www.qrd.alzheimers.org.uk/documents/AlzheimersSociety_ResearchStrategy_Aug2005.pdf.

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