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PL2. Prevention

Detailed programme, abstracts and presentations

PL2.1. Prevention of institutionalisation and hospitalisation: What place for case management? – Findings of a Cochrane Review

Orrell Martin, Reilly Siobhan, Toot Sandeep, Miranda-Castillo Claudia, Hoe Juanita, Challis David, Malouf Reem

Background: Case management aims to organise and coordinate care services to provide long-term care for people with dementia as an alternative to admission to a care home or hospital.

Objectives: To evaluate the effectiveness of case management for people with dementia on delaying institutionalisation, improving quality of life and reducing hospitalisations.

Design:We searched databases including the Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS and ongoing clinical trial databases for case management studies including randomised controlled trials involving people with dementia living in the community and their carers. Outcomes included institutionalisation, hospital admissions, mortality,  patient mental health, patient and carer quality of life, and carer burden. Data was extracted and checked by two reviewers.

Results: 13 trials (9,615 participants) were included in this review. Four trials provided data on admissions to care homes results significantly favoured the case management group at 6 months but not for other time points. Results from three trials found no clear evidence that case management improved quality of life for people with dementia or carers. Three trials provided data on carer wellbeing and at 6 months a significant improvement was shown for case management. Eight trials assessed carer burden and benefit for the case management group was found at 6 months. Six trials provided data on behaviour and this significantly favoured case management at 10-12 months, and also at 18 months (3 trials). There was no evidence of benefit to patient depression (3 trials), functional abilities (3 trials), or cognition (6 trials).

Discussion: This review provides good evidence for the benefits of case management for people with dementia in terms of: (1) reduced admissions to institutional care, (2) reduced behaviour disturbance, (3) improved carer burden and wellbeing. Case management may involve higher use of community services but this is offset by a lower use of acute services and hospitalisations. In most studies, case management was one aspect of a broader programme of care making it difficult to study the specific effects in detail. It is reasonable to conclude that case management is effective for both the person with dementia and their carer. Future studies should use process measures to demonstrate the extent to which case management is delivered and provided.

PL2.2. An overview of our current understanding of the prevention of dementia

Ngandu Tiia

Epidemiological studies indicate that Alzheimer’s disease (AD) is a multi-factorial disease with several modifiable risk factors. This presentation will review and illustrate current status and future directions in AD prevention.

Dementia and cardiovascular disease (CVD) prevention have more in common than previously thought. The Cardiovascular Risk Factors, Aging and Dementia (CAIDE) study is one of the long-term observational studies, that has indicated several modifiable risk factors for AD, and their interactions with genetic factors. CAIDE study has also enabled studying differences in risk factor profiles at midlife and late-life and risk factor dynamics over time in relation to cognitive changes. Scoring tools for estimating dementia risk in different age groups (short-term and long-term prediction tools) have been recently formulated. Such tools are necessary for selecting participants in prevention clinical trials. They are also important for health education and community planning.

Previous preventive trials with single agents in elderly or cognitively impaired persons have yielded disappointing results. Possible reasons for this and future directions in planning preventive interventions will be summarized. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is currently ongoing multi-domain intervention study primarily designed to delay cognitive impairment among high-risk individuals. The 2-year intervention has four main components: nutritional guidance; physical activity; cognitive training and social activity; intensive monitoring/management of vascular risk factors. Experiences from the FINGER study will be presented.  A lifelong perspective is needed for managing AD. Lessons learned from CVD prevention can be integrated to dementia research on the way from knowledge to action.

PL2.3. Preventing behavioural problems and avoiding the use of anti-psychotics – the Toolbox of the ALCOVE project

Leperre-Desplanques Armelle

Overprescribing of antipsychotics for the behavioural disorders in dementia represents a major worldwide safety & ethical issue that has been underlined by the World Health Organisation [1]. It is well known today that chronic exposure to antipsychotics (AP) is non-effective and deleterious for people living with dementia as it can lead to falls, excessive sedation, stroke and an increased risk of mortality, with an overall profoundly negative impact on the individual’s health, ability to communicate and quality of life.

The ALCOVE network has provided the opportunity to make a statement in Europe on the crucial issue of iatrogenicity and overuse of antipsychotics in dementia, identified by the European Medicine Agency [2] as a priority research for 2013. In Europe, methods, references, tools and expertise are available in the field of safety & antipsychotics risk reduction. These successful experiences might be useful for those European countries wishing to promote risk reduction programmes.

To avoid deferring to other sedative drugs or physical restraints & to achieve improvements in outcome for people living with dementia, antipsychotics reduction in behavioural and psychological symptoms of dementia (BPSD) should be developed along with BPSD prevention and management improvement, using non pharmacological alternatives to antipsychotics and individualised patient and carer interventions, including psychosocial interventions.

ALCOVE European Member States have chosen to build a shared Toolbox to tackle the safety issue of limiting antipsychotics in dementia. This Toolbox provides concrete tools, key messages and experiences for all actors and in all dimensions of care: dedicated risk measurement & risk reduction programmes, timely diagnosis, prevention & management of BPSD, and ethics in practice, all related to the use of antipsychotics.

PL2.4. Preventing carer burn-out: from co-victim treatment to carer empowerment

Vernooij-Dassen Myrra

Preventing carer burn-out is on the research agenda for more than 30 years. This research aims to provide healthcare practitioners with evidence to improve prevention of carer burn-out in daily practice. The acknowledgement of the burden of caring for a person with dementia stimulated an approach in which family carers haven been perceived as persons in need for emotional and practical support and thereby stimulated treatment as co-victims. This was an important step at the time. The most effective psychosocial interventions to prevent carer burn-out were multi-component, tailor made, offered the opportunity to make choices and were aimed at patient and caregiver. Examples of effective interventions were family counselling, occupational therapy training and psycho-education.

However, many other psychosocial intervention studies fail to show positive effects. There are several reasons for ineffectiveness. The timing is important. It’s obvious that being too late does not contribute to prevention, but interventions can also be too early. For instance, case management after screening for dementia was not effective. People refused to be managed. The same case management intervention is highly valued in a later phase when the complexity of problems is acknowledged by the family. Ineffective interventions might not meet the needs of family carers. Carers seem to desire an active role and a co-victim treatment might not fully meet this need.

Despite great progress in psychosocial intervention research, the large number of ineffective studies requires new approaches. New innovative concepts and interventions might lead to more effectiveness, such as the consideration of reciprocity, social inclusion and partnership. They refer to basic human needs and focus on citizenship rather than on carers being co-victims. Reciprocity refers to the carers as giving persons and to their wish to get something back. Carers perceive themselves as giving persons and like to be recognised as givers, not as persons in need for care. Receiving support is sometimes perceived as incompetence in caring and this perception should be taken into account when offering support. Social inclusion emphasises the need of the person with dementia and the carer to be part of society and not to be excluded because of the stigma attached to dementia. Inclusion of carers in designing interventions might contribute to its effectiveness. Partnership with family carers by recognition of the contributions might promote reciprocity and the recognition of capabilities. These new approaches empower carers rather than treating them as co-victims.

Psychosocial intervention research has room for improvement, but its results already have the potential to prevent carer burn-out. An important problem is implementation: how to put interventions into daily practice. Even effective interventions are rarely used in daily practice. With better use of the existing effective interventions and new innovative interventions psychosocial interventions have a high potential to improve the quality of life of family carers.



Last Updated: Wednesday 06 November 2013


  • Acknowledgements

    The 23rd Alzheimer Europe Conference in St. Julian's, Malta received funding from the European Union, in the framework of the Health Programme. Alzheimer Europe and the Malta Dementia Society gratefully acknowledge the additional support provided by foundations and companies.
  • European Union