Maintenance of function and independence, and specific interventions for cognitive symptoms in dementia
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
Clare Taylor, DPhil, MPhil, BA, is editor, National Collaborating Centre for Mental Health; Karen Harrison Dening, MA, RMN, RNMH, RGN, is consultant admiral nurse, Barnet, Enfield and Haringey Mental Health NHS Trust; Alan Duncan, BMedSci, was a systematic reviewer for the NICE guideline on dementia; Tim Kendall, MRCPsych, MBChB, BMedSci, is joint director, National Collaborating Centre for Mental Health, deputy director, Royal College of Psychiatrists’ Research and Training Unit, and consultant psychiatrist and medical director, Sheffield Care Trust.
Taylor, C. et al (2009) Therapeutic interventions in dementia 1: cognitive symptoms and function. Nursing Times; 105: 1, 16–17.
The first in this two-part unit on therapeutic interventions in dementia outlines how to maintain function and independence for patients with dementia. It also examines specific interventions for cognitive symptoms.
NICE and the Social Care Institute for Excellence (SCIE) recently developed a national guideline on supporting people with dementia and their carers (NICE and SCIE, 2006). It identifies the main therapeutic interventions and when they should be used.
People with dementia are likely to respond differently to the variety of psychological and pharmacological management strategies. Nurses need to be aware of the full range of interventions, know which ones may be most appropriate for an individual, and understand how to recognise whether an intervention is helping. The guidance identifies the main principles for promoting independence and maintaining function, which is a vital aspect of treatment and care.
This guidance categorised interventions in dementia care by therapeutic goal and in relation to the following three major areas:
- Maintaining function (including cognitive function);
- Managing behaviour that challenges;
- Reducing co-morbid emotional disorders.
Part 2 looks at the second and third areas.
Promoting independence and maintaining function
Care and nursing
The principal focus of care should be on maximising independent activity and enhancing function. Often this will involve helping patients to adapt and develop the skills to minimise their need for support.
This should start in the early stages of the condition and may involve many services and the patient’s carers and wider social network.
Providing care in a manner that promotes independence is likely to take more time but it is the core therapeutic intervention for people with dementia.
The NICE and SCIE (2006) guideline identifies key interventions that should be used to maximise functioning.
Care plans are vital and should include activities that are important for independence. They should take account of the individual’s needs, type of dementia, preferences, interests and life histories.
Good communication is at the heart of all effective psychological interventions. This entails being aware of non-verbal cues and speaking appropriately for patients’ levels of comprehension, sensory abilities and culture. The written word or pictures may also be helpful. It is important to appreciate that some patients may need vision and hearing tests. Working with people with dementia requires flexibility because their abilities may fluctuate and this needs to be accommodated. Advice and skill training on activities of daily living should be given by occupational therapists (see Box 1).
Box 1. Activities of daily living skill training
This involves assessing a person’s abilities, impairments and their capacity to perform everyday tasks (such as dressing, feeding and washing) to understand the underlying physical, psychosocial and neurological factors involved.
Individual programmes may be developed to enable people to perform as many everyday tasks as possible by themselves. The programmes include graded assistance, whereby carers give the least amount of assistance needed at each step to help patients to complete the task.
Strategies may include verbal or visual cues demonstrating how to perform the task, physical guidance, partial physical assistance and problem-solving (Pool, 2002; Beck et al, 1997).
Any environmental modifications that might aid independence, including assistive technology, should be considered. This might require advice from an occupational therapist and/or clinical psychologist.
Obtaining advice on independent toilet skills is important – if incontinence occurs, all causes should be assessed and treatment options tried before concluding that incontinence is permanent.
Physical exercise should be facilitated and encouraged where possible, with assessment and advice from a physiotherapist when needed. Exercise is thought to help improve continence, slow loss of mobility and improve strength, balance and endurance. It is also used in falls prevention (NICE, 2004).
It is vital to provide support to enable people to do things in their own time and to continue to take part in activities they enjoy. Consistent and stable staffing and familiar environments are important and relocations should be avoided.
In people with learning disabilities newly diagnosed with dementia, the Assessment of Motor and Process Skills can help in developing a care plan. This should be carried out by staff with formal training in its use.
Specific interventions for cognitive symptoms
Cognitive symptoms, that is, those affecting thought processes and memory, are integral to any definition of dementia. The NICE and SCIE guidance (2006) aimed to forge the link between improving cognitive symptoms and maintaining day-to-day functioning. The guideline development group considered this when assessing the effectiveness of interventions for cognitive symptoms.
When assessing evidence for a range of non-pharmacological approaches to cognitive symptoms of dementia, the guideline development group found that people with mild to moderate dementia can benefit from participating in structured group cognitive stimulation approaches.
Cognitive stimulation entails exposure to and engagement with activities and materials involving some degree of cognitive processing. These should be appropriate to the group and person-centred. The emphasis should be on social activities that participants enjoy.
Alzheimer’s disease: the NICE and SCIE (2006) guideline incorporated recommendations from the NICE (2006) technology appraisal on acetylcholinesterase inhibitors. Donepezil, galantamine and rivastigmine should be considered for those with moderate Alzheimer’s disease (a Mini Mental State Examination [MMSE] score of 10–20 points) only. Treatment should be initiated only by a specialist in dementia care – in most cases, this would be a psychiatrist or GP with a special interest in dementia care, although some nurse prescribers can undertake the secondary prescribing of these drugs.
The NICE and SCIE guideline advises that healthcare staff should not rely on the MMSE score in the following patients:
- Those with a score above 20 but who still have moderate dementia as judged by significant impairments in functional ability and personal and social function;
- People with a score below 10 who have linguistic difficulties but who have moderate dementia as judged by an assessment tool appropriate to their level of competence;
- Those who are not fluent in the language in which the MMSE is administered;
- People with learning disabilities – this group should be offered a different test specific to their needs.
The NICE and SCIE guideline incorporated other recommendations from the technology appraisal, including:
- Memantine (an N-methyl-D-aspartate (NMDA)-receptor antagonist) should not be used in people with moderately severe to severe Alzheimer’s disease except as part of well-designed clinical trials;
- Those with mild Alzheimer’s disease taking an acetylcholinesterase inhibitor and those with moderately severe to severe Alzheimer’s disease taking memantine may continue to receive it until they, their carers and/or specialist consider that it is appropriate to stop.
In addition to secondary prescribing of drugs for dementia, nurses have an important role to play in monitoring their effects on function and any adverse effects.
Non-Alzheimer’s dementias and mild cognitive impairment: acetylcholinesterase inhibitors and memantine should not be used to treat cognitive decline in vascular dementia (NICE, 2006). Acetylcholinesterase inhibitors should not be used to treat mild cognitive impairment.
Interventions for cognitive symptoms of dementia comprise psychological and pharmacological treatments. However, providing supportive care that encourages patients to maintain as much independent functioning as possible is perhaps as important as any specific interventions for cognitive symptoms.
Part 2 of this unit looks at the interventions for non-cognitive symptoms of dementia.
Portfolio pages online
Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.
Beck, C. et al (1997) Improving dressing behaviour in cognitively impaired nursing home residents. Nursing Research;
NICE, Social Care Institute for Excellence (2006) Dementia: Supporting People with Dementia and their Carers
in Health and Social Care. London: NICE.
NICE (2006, amended 2007) Alzheimer’s Disease: Donepezil, Galantamine, Rivastigmine (Review) and Memantine. London: NICE.
NICE (2004) Falls: The Assessment and Prevention of Falls in Older People. London: NICE.
Pool, J. (2002) The Pool Activity Level Instrument for Occupational Profiling of People with Cognitive Impairment. London: Jessica Kingsley.