the canadian alzheimer - sta communication inc

The Canadian Consensus Conference on Dementia: A GP’s Perspective 6Paul J. Coolican, MD, CCFP

Summary of the Canadian Consensus Conference on Dementia 8Christopher Patterson, MD, FRCPC

Sleep Disorders in Alzheimer Patients and their Caregivers: Part II 14Bernard Groulx, MD, FRCPC

Art Therapy: An Intervention for People with Alzheimer’s Disease 18Elizabeth M. Ginn, BFA, BA, Graduate Diploma

Challenging Behaviors in Alzheimer’s Disease: What Do We Know? 20Dorothy A. Forbes, RN, PhD

The Canadian

AlzheimerDisease ReviewVolume 3, Number 2 September 1999

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CHAIRMANPeter N. McCracken, MD, FRCPC

Geriatric Medicine StaffGlenrose Rehabilitation HospitalDirector, Geriatric Medicine and

Professor of MedicineUniversity of AlbertaEdmonton, Alberta

Paul J. Coolican, MD, CCFP Family Physician, St. Lawrence Medical Clinic

Morrisburg Ontario Active Staff,Winchester District Memorial

HospitalWinchester, Ontario

Shannon Daly, RN, BScNCommunity Nurse

Northern Alberta Regional Geriatric ProgramEdmonton, Alberta

Howard Feldman, MD, FRCPCClinical Associate Professor of Medicine

University of British ColumbiaDivision of Neurology UBC

Director, UBC Alzheimer Clinical Trials UnitVancouver, British Columbia

Serge Gauthier, MD, CM, FRCPCProfessor of Neurology and Neurosurgery,Psychiatry and Medicine, McGill University

McGill Centre for Studies in AgingMontreal, Quebec

Bernard Groulx, MD, CM, FRCPC Chief Psychiatrist, Ste-Anne-de-Bellevue Hospital

Associate Professor, McGill UniversityMcGill Centre for Studies in Aging

Montreal, Quebec

Nathan Herrmann, MD, FRCPCAssociate Professor, University of Toronto

Head of the Division of Geriatric Psychiatry,Sunnybrook Health Science Centre

Toronto, Ontario

Kenneth J. Rockwood, MD, FRCPCAssociate Professor, Dalhousie University

Geriatrician, Queen Elizabeth II Health Sciences Centre

Halifax, Nova Scotia

The Canadian Alzheimer Disease Review is published by STA Communications Inc., through an educational grant provided by Pfizer Canada.The opinions expressedherein are those of the authors and do not necessarily reflect the views of the publisher or the sponsor. Physicians should take into account the patient’sindividual condition and consult officially approved product monographs before making any diagnosis or treatment, or following any procedure based onsuggestions made in this document. Publications Agreement Number 1445057. Copyright 1999.All rights reserved.

Publishing StaffEditorial Board

2 • The Canadian Alzheimer Disease Review • September 1999

The editorial board has complete independence in reviewing the articles appearing in this publication and is responsible for their accuracy. Pfizer Canada exerts no influence on the selection or the content of material published.

We’d Like to Hear From You!The Canadian Alzheimer Disease Review welcomes letters from its readers. Address all correspondences to Letters, The Canadian Alzheimer Disease Review, 955 Boul. St. Jean,Suite 306, Pointe Claire, Quebec, H9R 5K3. The Review also accepts letters by fax or Internet.Letters can be faxed to 514-695-8554 and address electronic mail to [email protected]. Pleaseinclude a daytime telephone number. Letters may be edited for length or clarity.

On the CoverFields of Daffodils by Douglas L. ScrutonDoug Scruton is an Alzheimer patient at Trillium Ridge in Kingston, Ontario. Born in 1923,Doug Scruton married Dorothy M. Paget in 1949. He is the father of three children, the grand-father of four and he has one great-grandchild. After 29 years of service, he retired from BellCanada in 1982. Today, Doug Scruton participates in a program called Visions Through Art,which helps Alzheimer patients express themselves through painting. The group is lead by anartist and several assistants. Although help is provided for setting up, mixing paint and cleaningbrushes, the composition and all of the brush strokes are the artist’s own work.

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The Canadian Alzheimer Disease Review • September 1999 • 3

The United Nations declared 1999 "TheInternational Year of Older Persons". This focus

on the elderly is due in large part to demographicpressures occurring in Western societies. StatisticsCanada reports that approximately 12% of the popu-lation in Canada is currently 65 years of age or older,representing 3,725,000 people. This number isexpected to swell to 6,000,000 within the next twodecades. While this "greying" of society is generallyseen as positive, reflecting improvements in healthand living conditions, there isalso a darker side to this trend.The Canadian Study of Healthand Aging1 reported there are cur-rently over 250,000 elderly peoplewith dementia, and since aging isthe most important risk factor fordementia, it is estimated that thisnumber will triple in the next 30 years. How will we (patients,families, physicians and society)cope with this "epidemic"?

One solution includes health promotion and pre-vention. The impact of prevention or even delayingdisease onset cannot be overemphasized. Brookmeyeret al2 used Alzheimer's disease incidence data andmortality rates from the U.S. census and estimatedthat if the onset of the disease could be delayed by aslittle as five years, the relative risk reduction wouldbe 50%, representing a reduction of over 4,000,000cases of Alzheimer's disease over the next 50 years!Despite these obvious benefits, little has been writtenabout disease prevention in late life and few interven-tions have demonstrated success at delaying the onsetof dementia.

While little can be done about two major risk fac-tors for Alzheimer's disease, aging and genetics, thereare a number of studies that suggest possible inter-ventions. Epidemiologic studies have noted that the

lack of a formal education and head injuries are asso-ciated with the development of Alzheimer's disease.Health promotion should therefore include improvingbasic education and encouraging the use of seatbeltsand bicycle helmets to reduce head injuries. The earlydetection of hypothyroidism and assessing elderlypatients with cognitive impairment for potentiallyreversible causes of dementia such as B12 deficiency,alcohol abuse, chronic drug toxicity and normal pres-

sure hydrocephalusmight also be helpful.

The prevalence ofvascular dementiamight be reduced bytreating stroke-relatedrisk factors such ashypertension, smok-ing, diabetes, hyper-cholesterolemia andatrial fibrillation.Although the impact

of many of these interventions on the prevalence ofdementia is unknown, a recent study using a calciumchannel blocker to treat systolic hypertensionreduced the incidence of dementia 50% more thanplacebo.3 There is speculation that because hypertensionmay play a role in the development of degenerative demen-tias as well as vascular dementias, the reduction wouldinclude cases of Alzheimer's disease.

Emerging data have suggested that antioxidants(for example, vitamin E, selegiline), nonsteroidalanti-inflammatory drugs (NSAIDs) and post-menopausal estrogen replacement may delay theonset of Alzheimer's disease. Two cohort studies havesuggested that moderate to high doses of antioxidantvitamins reduce the incidence of Alzheimer's diseaseand cognitive impairment. One randomized con-trolled trial of patients with Alzheimer's disease,

E D I T O R I A L

Coping with Alzheimer’s Disease:A Milligram of Preventionby Nathan Herrmann, MD, FRCPC

The Canadian Study of Health andAging1 reported there are currentlyover 250,000 elderly people withdementia, and since aging is the mostimportant risk factor for dementia, it isestimated that this number will triplein the next 30 years.

demonstrated that vitamin E and selegiline had some

ability to delay progression to end-points such asdeath and institutionalization.4 A meta-analysis of 17 studies that examined the relation betweenNSAIDs and Alzheimer's disease suggested that rela-tive risk is reduced by more than 50%.5 Two largeprospective epidemiologic studies have shown thatpost-menopausal hormone replacement therapy low-ers the incidence of Alzheimer's disease.6,7 Althoughthese studies appear promising, it is premature to rec-ommend the use of NSAIDs and hormone replace-ment therapy to prevent dementia.8

Another possible prevention technique ischolinesterase inhibitors. Although it has generallybeen assumed that cholinesterase inhibitors such asdonepezil provide only symptomatic improvement inmild to moderate dementia, recent studies have sug-gested that they may also possess some disease-modifying effects. As a result, studies are currentlyunderway with a number of cholinesterase inhibitors tosee if they will reduce the incidence of Alzheimer's dis-ease in patients with minimal cognitive impairment.

Given that most of these prevention techniques arestill in the investigational stage, we need to determinewhat can be done to cope with this illness today.Certainly ensuring appropriate diagnosis as early aspossible and providing appropriate care in the form ofcognitive enhancement therapy, treatment of behav-ioral disturbances, psychosocial interventions andcaregiver support will help. To help clinicians copewith this daunting task, the Canadian ConsensusConference on Dementia has developed clinical prac-tice guidelines for the management of dementing dis-orders, which are summarized on page eight of thisissue. But do such guidelines actually get translatedinto practice? For most guidelines, the answer isunfortunately no.9 There are many factors that appearto affect the adoption of guidelines, including thequality of the guidelines, how well they fit with clin-icians' current practice patterns, legislative pressures,and patient pressures. The consensus guidelines ondementia deal with a serious prevalent illness thatrequires complex care, much of which can be accom-plished in the offices of primary care physicians. Therecommendations were developed with the help offamily physicians and have been endorsed by profes-sional organizations such as the College of FamilyPhysicians of Canada and the Alzheimer Society ofCanada. So what else is necessary to ensure that theseguidelines are adopted? Carefully designed continu-ing medical education is essential. Research has

demonstrated, however, that traditional methods such

as didactic lectures and unsolicited mailings areessentially useless (though if you have read this farinto my editorial you have probably disproven this"fact"!) Stronger educational interventions includereminder systems, academic detailing and multipleinterventions. Whether such interventions will beused by those who developed the Canadian consensusguidelines is yet to be determined.

The International Year of Older Persons will helpsociety focus more attention on the elderly and high-light illnesses such as dementia. This recognition isan important first step on a journey that will end withour ability to prevent dementing illnesses. Untileffective prevention techniques are developed, how-ever, clinicians can rely on evidence-based practicerecommendations, such as those of the CanadianConsensus Conference on Dementia, to improve thequality of life for people with these illnesses.

Nathan Herrmann

References1. Canadian Study of Health and Aging Working Group.

Canadian study of health and aging: study methods andprevalence of dementia. CMAJ 1994; 150:899-913.

2. Brookmeyer R, et al: Projections of Alzheimer's disease inthe United States and the public health impact ofdelaying disease onset. Am J Public Health 1998;88:1337-42.

3. Forette F, et al: Prevention of dementia in randomiseddouble-blind placebo-controlled systolic hypertension inEurope (Syst-Eur) trial. Lancet 1998; 352:1347-51.

4. Sano M, et al: A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer's disease.N Engl J Med 1997; 336:1216-22.

5. McGreer PL, et al: Arthritis and anti-inflammatory agentsas possible protective factors for Alzheimer's disease: areview of 17 epidemiological studies. Neurology 1996;47:425-32.

6. Kawas C, et al: A prospective study of estrogenreplacement therapy and the risk of developingAlzheimer's disease. The Baltimore Longitudinal Study ofAging. Neurology 1997; 48:1517-21.

7. Teng M, et al: Effect of estrogen during menopause onrisk and age at onset of Alzheimer's disease. Lancet 1996;348:429-32.

8. American Psychiatric Association: Practice guidelines forthe treatment of patients with Alzheimer's disease andother dementias of late life. Am J Psychiatry 1997;154(Suppl):5.

9. Davis DA, et al: Translating guidelines into practice: asystemic review of theoretic concepts, practicalexperience and research evidence in the adoption of


E D I T O R I A L


Over the last few years, primary care physicianshave been exposed to an increasing number of

Clinical Practice Guidelines (CPG). These arederived from the recommendations of a national orinternational group of specialists who hold a consen-sus conference. The group reviews current evidenceand compiles a useful set of recommendations. InCanada, consensus-derived CPGs have been releasedin many fields and the degree to which they have beenadopted by primary care physi-cians has been varied.

Canadian guidelines for themanagement of hypertensionhave been slow to be imple-mented both in primary careand specialty groups. Amongthe most accepted CPGs wouldbe the advanced cardiac life support recommenda-tions of the American Heart Association. As a gener-al rule, the more concrete the problem, the easier it isto arrive at a set of recommendations that will beaccepted and implemented.

In this light, it is a major accomplishment that theCanadian Consensus Conference on Dementia hasdeveloped a broad set of recommendations thatshould prove valuable in primary care. Dementia is agroup with conditions of multiple and often overlap-ping causes. These conditions manifest themselves ina variety of presentations but share the common fea-ture of cognitive decline in the absence of delirium oracute illness. The management of dementia occupiesa disproportionately large portion of many primarycare practices. These patients are poor historians,they often live alone or with an elderly spouse, theyhave a high rate of concomitant morbidity (which is

difficult to diagnose and treat) and they often have children in distant places who are unaware of theircondition. With these patients and their families, weoften practice the “art of medicine” rather than the“science of medicine”.

The Canadian Consensus Conference onDementia is a welcome summary of recommenda-tions based on current literature and it addressessome of the more difficult and broader issues of

dementia. Ethical issues,caregiver issues and culturalissues are addressed withoutsacrificing the pertinent clini-cal data. Forty-eight recom-mendations are made. I foundthe recommendations on com-puted tomography scanning,

laboratory work, screening, genetic testing and pre-vention particularly interesting.

Recommendations on pharmacotherapy addressissues of vitamin E and gingko biloba as well as theuse of donepezil in Alzheimer’s dementia. Four rec-ommendations are made concerning the managementof behavioral disturbances, including nonpharmaco-logic strategies. These recommendations address theneed to regularly re-evaluate ongoing treatment forpatients who require medication.

The human mind continues to demonstrate a won-derful variety of forms that confirm our uniquenessand collective similarities, both in the cognitivelyimpaired and the cognitively intact. These featureswill continue to force those who care for the elderlyto find solutions to unique problems. These recom-mendations will help guide and reinforce appropriatecare for patients with dementia.

The Canadian Consensus Conference on Dementia:A GP’s Perspective

by Paul J. Coolican, MD, CCFP

The management of dementiaoccupies a disproportionatelylarge portion of many primarycare practices.


The CanadianConsensus Conferenceon DementiaThis article is a summary of the consensus statementsformulated by the conference on dementia for theassessment and management of dementia in primary care.

by Christopher Patterson, MD, FRCPC

Dr. Christopher Patterson, Professor,Division of Geriatric Medicine,McMaster University, Hamilton,Ontario.

As the Canadian population ages,the prevalence of dementia will

rise dramatically. There are approxi-mately 270,000 people with dementiacurrently in Canada; this number isexpected to rise to 778,000 by 2031.1

Manifestations of dementing disor-ders include not only cognitivedeficits (which make it difficult towork, drive, manage finances andmake decisions) but also behavioralcomplications (e.g., withdrawn oraggressive behavior, wandering, dis-inhibition).

Family physicians, who providethe majority of care for older people,must be skilled in the diagnosis andmanagement of dementia. A familyphysician with 1,200 patients mayhave 12 patients with dementia in theirpractice.

These facts underscore the impor-tance of developing clinical practiceguidelines (CPGs) for primary carephysicians. The Canadian ConsensusConference on Dementia (CCCD)used a rigorous process to obtain,select, grade and review evidence.Background papers were preparedand circulated to conference partici-pants, all of whom had expertise in

dementia or a related area. Thesepapers were discussed and recom-mendations (consensus statementsupon which the CPGs are based) werefinalized at a conference in Montrealin February 1998. These recommen-dations have been published in a sup-plement to the Canadian MedicalAssociation Journal.2 A “physiciansguide” to their use has also been pub-lished.3 The recommendations aresummarized here, but the reader isencouraged to read the supplement,which summarizes the evidence forthese statements. The supplement isalso available at www.cma.ca.

Types of DementiaAlzheimer’s disease (AD) is by far themost common cause of dementia inCanada, accounting for more than 60%of all cases. Vascular dementia is lesscommon, and people previouslythought to have vascular dementiaoften have co-existent AD. Patientswith frontotemporal dementia usuallyshow signs of early behavior problemsand language involvement. Dementiawith Lewy bodies is characterized byearly hallucinations and delusions,extrapyramidal side effects, sensitivity

to neuroleptics and a marked day-to-day fluctuation in confusion.

Dementia—A Clinical Diagnosis Although some aspects of cognitiveperformance deteriorate with age, cog-nitive losses that lead to decliningfunction in occupational, social or day-to-day functioning are associated withdementia. If mental status testinguncovers objective evidence of memo-ry loss or decline in other areas, theability to perform daily activitiesshould be assessed.

The most important aspect of estab-lishing a diagnosis of dementia isobtaining a thorough history from thepatient, and a corroborative history fromcaregivers. The history should include adescription of the onset, course andduration of the problem. Inquiriesshould be made about previous psychi-atric problems (e.g., depression), riskfactors (e.g., substance abuse, vasculardisease, family history) and neurologi-cal symptoms (e.g., new onsetheadache). A physical examinationshould include a search for systemicdisease, focal neurological signs and amental status evaluation. The Mini-

Mental State Examination (MMSE)4 isa good starting point, but other cognitivedomains (e.g., insight, judgment)should also be assessed. A review of allprescription and nonprescription med-ications is essential. This informationwill often point to a specific diagnosis.

Laboratory Tests for All PatientsIn the past, emphasis has been placed oninvestigations to rule out “reversible”causes of dementia. Because these

reversible causes are much less com-mon than previously thought,5 empha-sis is now on confirming the diagnosison the basis of the patient’s history. Forexample, AD is typified by a gradual,insidious loss of memory, usually fol-lowed by difficulties with language,praxis (performing familiar tasks) andvisuospatial disturbances such asagnosias (failure to recognize familiarpeople or surroundings). Behavioralproblems usually appear later in thecourse of the disease. The average dura-tion of the disease from onset to death isabout seven years.

Tests for patients who display typ-ical cognitive symptoms or presenta-tion include a complete blood countand measurement of thyroid stimulat-ing hormone, serum electrolytes,serum calcium and serum glucoselevels. In atypical cases, laboratorytests may be indicated.

Neuroimaging, most commonlycomputed tomography (CT), can detectcertain causes of dementia such as vas-cular dementia, tumor, normal pressurehydrocephalus or subdural hematoma;it is ineffective in distinguishing AD orother cortical dementias from normal

aging. CT scans should be restricted tothose people who meet the criteria inTable 1. Adhering to these “rules”reduced the number of scans performedin a memory clinic by two thirds.6

ReferralsTypical characteristics of AD are insidi-ous onset, progressive decline overseven to 10 years, and a gradual loss ofcognitive and functional abilities.Physicians are encouraged to seek help

when patients do not follow this typicalpattern (e.g., those who manifest earlybehavioral changes or delusions, fluctu-ating course, early motor changes) orwhen management difficulties arise(Table 2).3

Early DetectionDementia can be detected early if thefamily physician maintains a high indexof suspicion in elderly patients and fol-lows up observations of functionaldecline and memory loss. Memorycomplaints should be evaluated. Whencaregivers report cognitive decline in apatient, cognitive assessment and care-ful follow-up are indicated. There iscurrently insufficient evidence to rec-ommend screening with short mentalstatus questionnaires for cognitiveimpairment in the absence of symptomsor in unselected older people.

Genetic CounsellingGenetic counselling is recommendedwhen there is a strong family history of


Table 1

CT Scans Are Recommended for Patients• younger than 60 years of age,• who have a rapid unexplained

decline in cognition or function(over one to two months),

• who have a short duration ofdementia (less than two years),

• who have had a recent and significanthead trauma, unexplained neurologicsymptoms (e.g., new onset of severeheadache or seizures),

• who have a history of cancer (especial-ly in sites and types that metastasize tothe brain) use anticoagulants or have ahistory of a bleeding disorder,

• who have a history of urinary inconti-nence and gait disorder early in thecourse of dementia (as may be foundin normal pressure hydrocephalus),

• who have any new localizing sign(e.g., hemiparesis or a Babinski reflex),

• who have unusual or atypical cog-nitive symptoms or presentation(e.g., progressive aphasia),

• or have gait disturbance.

Dementia can be detected early if the family physicianmaintains a high index of suspicion in elderly patientsand follows up observations of functional decline andmemory loss. Memory complaints should be evaluated.When caregivers report cognitive decline in a patient, cog-nitive assessment and careful follow-up are indicated.

Figure 1

Diagnosis of Dementia


No

Yes

Yes

No

Are there other causes for the

symptoms?

Caregiver confirms

Dementia excluded as a possible diagnosis.Symptoms may be theresult of depression oranxiety. Re-evaluate in

3 to 6 months.

Diagnosis of dementiaconfirmed.

Treat these causes

Conduct physical examinations

Conduct laboratory tests CBC, TSH, electoytes, calcium, glucose

Conduct other tests as indicated(CT or MRI in specific cases*)

Suspectdementia

Subjectivecomplaints

Complaints of memory loss

Take history of illness from patient and reliable informant. Include:• onset of symptoms• duration of symptoms• evolution of symptoms• precipitating factors• family history

Eliminate presence of reversible conditions:• substance abuse• adverse drug effects• depression• metabolic disorders• systemic illness

Conduct mental and functional assessment

(e.g., MMSE and FAQ)

Objective evidence ofcognitive decline

Decline in functionYes

Yes

No

No

* See table of indications


Figure 2

Treatment of Alzheimer’s disease (AD)

Diagnosis of AD

Provide support and education for caregiver andrefer to support organizations

Disclose diagnosis to patient and family

Are there contributory or treatable causes

of dementia?

Yes

No

No

Re-assess in 3 monthsRepeat baseline measures

Establish baseline measuresMMSEMeasure of function (e.g., FAQ)Begin caregiver diary

YesImprovement in measures

Treat contributory causes(e.g., hypothyroidism,reduce sedative drugs)

Reconsider diagnosisand/or treatment and

refer to specialist

Initiate treatment with donepezil for informed andwilling patients with no contraindications

Re-assess regularly

Continue treatmentwith donepezil

Alzheimer’s disease, particularly whenthe onset is below the age of 60.

Risk Factors and Prevention of DementiaThe risk of dementia may be reduced byeffectively treating vascular risk factors(e.g., hypertension, diabetes, smoking,atrial fibrillation).6 Recent evidencesuggests that substandard education(less than six years), head trauma,Down syndrome, and family historymay increase the risk of AD. Thisopportunity for prevention has beenunderused in the past.

Although evidence is currentlyinsufficient to recommend estrogenreplacement, (NSAIDs) or antioxidantsto prevent dementing disorders, this isan area of active research. Some author-ities encourage the use of vitamin E,because it is relatively harmless, inex-pensive and may be beneficial.

Ethical IssuesThe wide scope of ethical issues suchas participation in research, decisionmaking, respecting individuals’ deci-sions, quality of life, behavior control,use of restraints, advance directivesand end-of-life decisions have beendealt with elsewhere.7 The CCCD rec-ommendations deal with only two spe-cific issues: disclosure and driving.Ethical analysis concludes that, in gen-eral, diagnosis should be disclosed topeople with dementia. Disclosureallows the patient to set out advancedirectives and make end-of-life deci-sions.7 Office assessment of drivingability is notoriously inaccurate. Whenin doubt, a performance-based assess-ment (including an on-road test) more

accurately defines driving risk.Although the risk of crashes increase asdementia progresses, there is no definiteage or MMSE score before which dri-ving can be confidently assumed to besafe. Sedative drugs increase the risk ofcrashes.8

Caregiver IssuesSolid partnerships between primarycare physicians and caregivers helpfamilies cope with their role.Caregivers are in a position to monitorstatus and symptoms and should beincluded in treatment planning.Physicians can help caregivers byacknowledging the value of their work,educating them about the disease andhelping them deal with stress.

Support for caregivers is the mostimportant aspect of managing ademented person. Various strategiesand support organizations can greatly

help the caregiver. A program of edu-cation, case management and supportfor the caregiver from the AlzheimerSociety has been shown to delay apatient’s admission to a long-term careinstitution by approximately one year.9

Support programs can also providecaregivers with information about legaland financial issues.

Cultural AspectsIn some cultures the concept ofdementia does not exist. Conventionalmental status tests frequently overes-timate the cognitive deficits of peo-ple from different linguistic andcultural groups. It is important toprovide services that are culturallyappropriate.

Depression and DementiaDepression is extremely common inearly stages of AD. Physicians shouldconsider a diagnosis of depression whenpatients experience behavioral symp-toms, weight and sleep changes, sad-ness, crying, suicidal statements orexcessive guilt. Nonpharmacologictherapy should be initiated if depressivesymptoms are not part of a major affec-tive disorder, severe dysthymia orsevere emotional lability. Medicationshould be considered for more severedepression. Selective serotonin reuptakeinhibiors (SSRIs) and reversibleinhibitors of monoamine oxidase A(RIMA) antidepressants are generallypreferred over tricyclic antidepressants(TCAs), which have anticholinergiceffects that can aggravate cognitivedeficits.10 Individuals with AD are par-ticularly sensitive to anticholinergicagents. Referral to a specialist may benecessary if the depression is atypical orrefractory.

Behavioral Problems Behavioral difficulties are common andare often the most challenging compli-cations of a dementing illness. It isimportant to evaluate causes and todocument behavior carefully beforeresorting to pharmacologic treatment.11

Table 2

Refer Patients to Other Health Care Professionals • if diagnosis is uncertain after the initial

assessment and follow-up, • if the patient or his or her family want

a second opinion,• in the presence of significant depres-

sion (especially if there is no responseto treatment, treatment problems orfailure with new medications for AD),

• if the need arises for additional help inpatient management (e.g., behavioralproblems) or caregiver support,

• when genetic counselling is indicated, • when research studies into diagnosis

or treatment are being carried out.


Physicians can help caregivers by acknowledging thevalue of their work, educating them about the diseaseand helping them deal with stress. Support for care-givers is the most important aspect of managing ademented person.

Environmental modifications (changesto sound, light, people) are often effec-tive. The value of neuroleptic drugs hasbeen overestimated in the past, and ingeneral, a cautious approach is recom-mended, using low doses, cautiousescalation and careful observation. Thenewer atypical neuroleptics may offeradvantages over traditional agents.12 Ifsymptoms are successfully controlledwith pharmacotherapy, physiciansshould regularly evaluate the need forcontinuing treatment and reduce orwithdraw the drugs if possible.

Pharmacologic Management of DementiaThe goal of therapy is to halt or slowcognitive and functional decline,improve memory and other cognitivefunctions, maintain or improve the abil-ity to perform daily activities, improvebehavioral abnormalities, and improvemood, contentedness and quality of lifeof the patient, which will also improvethe quality of life of the caregiver. Noneof the drugs that are currently availablemeet all of these criteria, but sympto-matic treatment is available.

Donepezil is currently the only med-ication approved by Health Canada totreat mild to moderate AD.13,14 Baseline

assessments should be made before pre-scribing donepezil, and serial examina-tions should be conducted to determinewhether the medication is effective. Inaddition to the physician’s assessment(which should include cognitive (e.g., MMSE4) and functional measures(e.g., functional assessment question-naire15)) caregivers of the affected indi-vidual should be encouraged to recordtheir observations in a daily diary andshould be given realistic expectations.

There is currently insufficient evi-dence to recommend vitamin E orGinkgo biloba therapy for patientswith AD.

ConclusionsThe foregoing is a brief summary of theconsensus statements formulated by theCanadian Consensus Conference onDementia for the assessment and man-agement of dementia in primary care.This should be used only as a guide; thereader is urged to review the full recom-mendations published in CMAJ2 andthe “physicians guide” to their use.3

Funding SupportThe conference organizers would like toexpress their appreciation to the follow-ing organizations for providing grants in

support of the Canadian ConsensusConference on Dementia: BayerHealthcare Division; BoehringerIngelheim Canada Ltd.; HoechstMarion Roussel; Janssen-OrthoPharmaceutical Inc.; NovartisPharmaceuticals Canada Inc; PfizerCanada Inc.; SmithKline BeechamPharma; Consortium of CanadianCentres for Clinical CognitiveResearch; Division of GeriatricMedicine, McMaster University;Division of Geriatric Medicine, McGillUniversity; McGill Centre for Studies inAging.

EndorsementThe following organizations endorsed consensus recommendations:Alzheimer Society of Canada;Canadian Academy of GeriatricPsychiatry; Canadian Society ofGeriatric Medicine; College of FamilyPhysicians of Canada; Consortium ofCanadian Centres for ClinicalCognitive Research (C5R); CanadianNeurological Society; and the Sociétéquébécoise de gériatrie. Members ofthe steering committee included: Drs.C. Patterson, S. Gauthier, H. Bergman,C. Cohen, J. Feightner, H. Feldman,A. Grek, and D. Hogan.


References1. Canadian Study of Health and Aging

Working Group: Canadian study ofhealth and aging: study methods andprevalence of dementia. CMAJ 1994;150:899-913.

2. Patterson CJS, Gauthier S, Bergman H,et al.: The recognititon andmanagement of dementing disorders:conclusions from the CanadianConsensus Conference on Dementia.CMAJ 1999;160 (Suppl 12).

3. Patterson CJS, Gauthier S, Bergman H,et al.: Canadian Consensus Conferenceon Dementia: a physicians' guide tousing the recommendations. CMAJ1999; 160:1738-42.

4. Folstein MF, Folstein SE, McHugh PR:“Mini Mental State”: a practicalmethod of grading the cognitive stateof patients for the clinician. J Psychiatry Res 1975; 12:189-98.

5. Clarfield AM: The reversible

dementias: do they reverse? Ann InternMed 1988; 109:476-86.

6. Freter S, Bergman H, Gold S, et al.:Prevalence of potentially reversibledementias and actual reversibility in amemory clinic cohort. CMAJ 1998;159:657-62.

7. Tough issues: ethical guidelines. Toronto:Alzheimer Society of Canada, 1997.

8. Hemmelgarn B, Suisa S, Huang A, et al.:Benzodiazepine use and risk of motorvehicle crashes. JAMA 1997; 278:27-31.

9. Mittelman MS, Ferris SH, Shulman E, etal.: A family intervention to delay nursinghome placement of patients withAlzheimer's disease. A randomizedcontrolled trial. JAMA 1996; 276:725-31.

10. Wragg RE, Jeste DV: Overview ofdepression in Alzheimer's disease. Am J Psychiatry 1989; 145:577-87.

11. Beck CK, Shue VM: Interventions fortreating disruptive behavior in dementedelderly people. Nurs Clin North Am

1994; 29:143-55.12. Katz IR, Jeste DV, Mintzer JE, et al.:

Comparison of risperidone and placebofor psychosis and behavioral disturbancesassociated with dementia—arandomized, double-blind trial. J Clin Psychiatry 1999; 60:107-15.

13. Rogers SL, Friedhoff LT, theDonepezil Study Group. The efficacyand safety of donepezil in patientswith Alzheimer’s disease: results of aUS multicenter, randomized, doubleblind, placebo-controlled trial.Dementia 1996; 7:293-303.

14. Rogers SL, Farlow MR, Doody RS, et al.:A 24-week, double-blind, placebo-controlled trial of donepezil in patientswith Alzheimer’s disease. Neurology1998; 50:136-45.

15. Pfeffer RI, Kurosaki TT, Harrah CH:Measurement of functional activities ofolder adults in the community. J Gerontol1982; 37:323-9.


In the first part of this article,which appeared in the December

1998 issue of The CanadianAlzheimer Disease Review, I notedthat people with Alzheimer’s dis-ease (AD) are usually elderly andtheir caregivers are generally theirspouse. Because it is so difficult totake care of a loved one with AD, agood night’s sleep is essential.Elderly people often have sleep dis-orders or, more specifically, com-plain of sleeping poorly. This articlecompletes the preceding one and isaimed at helping clinicians dealwith sleep problems in patients withAD and their caregivers.1

The first article in this seriesstressed how important it is forfamily physicians to understand theprofound changes in sleep patternsthat occur as people age, and thatthey be able to explain this topatients. The importance of assess-ment and taking a complete familyhistory were also highlighted. Thiswill help identify habits of patientsand their caregivers that may beinterfering with their ability tosleep. It is hardly surprising thatthe first form of treatment is educa-

tion: reminding aging patients ofthe principles that lie behind a goodnight’s sleep (Table 1).

Nonpharmacologic TreatmentsOften family physicians don’t thinkof nonpharmacologic therapy as first-line treatment. The value of somenonpharmacologic treatments arewell substantiated at the scientificlevel although others are not. I feel itis important to describe a few of thesetreatments because so much is writtenon the subject and because they areeasily accessible. Family physiciansshould discuss the value of such treat-ments with their patients.

PsychotherapyWhen anxiety is the cause of sleep dis-orders, psychotherapy can often be ben-eficial in the long term. In many cases,it is the best choice. Psychotherapy cantake many forms: plain support or ther-apeutic contact relaxation techniques; orcognitive-behavioral, interpersonal orpsychodynamic.2

A “Traditional” RecipeTraditionally, when sleep was a longtime coming, hot milk and a few bis-

Sleep Disorders inAlzheimer Patients andtheir Caregivers: Part II

Elderly people often complain of insomnia or nonrestorativesleep. For the majority of people, making them aware of theirhabits will be sufficient to solve the problem, for others,alternative approaches will be required. A good night’s sleep isas important for the caregiver as it is for those withAlzheimer’s disease.

by Bernard Groulx, MD, CM, FRCPC

Dr. Groulx is Associate Professorat McGill University and Chief ofPsychiatry, Ste. Anne’s Hospital,McGill Centre for Studies inAging, McGill University,Montreal, Quebec.

cuits was the recommended cure.There is a scientific basis for thispractice: milk contains a great dealof tryptophan, a precursor of sero-tonin, one of the neurotransmittersinvolved in sleep. Tryptophan isabsorbed better when taken with car-bohydrates, such as cookies.

I have taken the trouble ofexplaining the potential benefits ofthis traditional recipe to my patients,often with very interesting results. Iam aware that the success of thistherapy may arise from the placeboeffect.

RelaxationClassic relaxation techniques (likethose of Jacobson) or subliminaltechniques can produce interestingresults and ease sleeping problems.

Water Beds In many American geriatric institu-tions, particularly in California,patients have the option of usingwater beds, which greatly diminishdecubital sores. It has been shownthat water beds contribute to bettersleep and considerably reduce thenumber of times patients wake,which is a problem for many elderlypeople.

Other OptionsI have witnessed some very interest-ing acupuncture sessions aimed atimproving sleep. I have seen surpris-ing results with techniques such asaromatherapy and massotherapyboth in my hospital and in numerousEuropean geriatric centres. In addi-tion, herb teas often produce far bet-ter results than neurotropic agents.

One has to keep an open mindabout so-called alternative medicine.In fact, some of these approacheswarrant in-depth study, especiallysince physicians are faced with somany complaints from elderlypatients who sleep poorly.

Different Sleep DisordersThere are five types of clinical sleepdisorders.3 We will briefly describethem here before looking at treatmentwith medication.

Difficulty falling asleep: Olderpeople often have difficulty fallingasleep, but once they are asleep, haveno problem sleeping through to themorning. Relaxation techniques canbe particularly helpful in such cases.

Difficulty staying asleep: Normalphysiological changes are amplified.People fall asleep quite well, butwake several times during the night,sometimes for long stretches. Supportand clear explanations about normalsleep patterns in the elderly can bethe solution.

Mixed: This type is a combinationof the difficulty falling asleep and dif-ficulty staying asleep.

Desynchronized sleep: In thesecases, elderly people sleep more dur-ing the day than at night. This prob-lem can often be attributed to the carefacilities involved. In many homes forthe elderly or geriatric hospitals,patients are encouraged (eitherdirectly or by a lack of stimulation) totake naps of one or two hours, some-times even twice a day. If thesepatients are put to bed at eight p.m.,or even earlier, it is not surprising that their sleep cycle is completed by the early hours of the morning.

Consequently, the older person willsleep during the late morning or earlyafternoon, and the cycle will berepeated. It is clear that in this case,changes in the environment would bemore appropriate than medication.

Day-night inversion: This prob-lem is found most often in patientswith dementia, and can sometimes bevery difficult to resolve. This situa-tion becomes intolerable very quick-ly, especially if the person is living athome. Pharmacotherapy is oftenrequired, as much for the patient withdementia as for the caregiver.

Pharmacologic ApproachesThe first pharmacologic approach isnot to add a medication, but rather toeliminate one. Indeed, many medica-tions interfere with sleep, especiallyin the elderly.

Family physicians should alwayscheck whether it is possible to eliminatethese drugs from the treatment regimen(Table 2). If the sleep problem is anxiety-based and nonpharmaceuticapproaches have not helped, benzodi-azepines can be prescribed. It should benoted, however, that clinical tests havedemonstrated that these agents provokeundesirable effects such as increasedcognitive deficiency in patients withAD. They can also cause excessive diur-nal sedation and are subject to toleranceand withdrawal symptoms.4


Table 1

Advice for Improved Sleep Habits• Only sleep the number of hours you need to feel refreshed; limit the amount of

time you spend in bed and keep it constant• Get up at the same time every day in order to stay on a constant circadian

rhythm; this will make it easier to fall asleep• Exercise daily at least four hours before going to bed• Avoid heavy meals before going to bed; a small snack may be useful• Reduce bright lights, reduce noise to a minimum and maintain a temperature of

21°C in the bedroom• Reduce or even eliminate the intake of substances like caffeine, nicotine and alcohol• Have short naps during the day, but avoid napping too often. • If you wake in the night and it takes more than 20 minutes to get back to sleep,

get up and do something until you feel tired again

For the caregiver, short-actingbenzodiazepines are preferred, espe-cially if someone is trying to decreasethe dose or stop taking the medicinealtogether.

Appropriate doses for geriatricpatients are in the order of 0.5 mg forlorazepam, 15 mg for oxazepam andto 15 mg for temazepam.

If the sleep disorder is due to amajor emotional disorder, an appro-

priate antidepressant will be the ther-apeutic pharmacologic solution.

Neuroleptics with a tranquilizingeffect should not be used unless theinsomnia is clearly caused by psy-chotic agitation or symptoms of thatnature. Although they are sometimesthe only effective pharmacologicsolution in cases of day-night inver-sion, a good basic principle toremember is one I call the “baseballlaw”: after three strikes, they’re out.Three clinical elements contribute tothe development of tardive dyskine-sia: age, sex (female), and the pres-ence of cognitive problems. Theseelements have even more effect inpeople with dementia. In young peo-ple it often takes years before tardivedyskinesia develops. In older people,especially older women with cogni-tive problems, it can develop in just afew months. Trazodone is very popu-lar for treating insomnia in the elder-ly, including those with dementia.The dose can be as low as 25 mg at

bedtime. It can be increased gradu-ally to 100 mg to obtain the desiredsedative effects. It is rare for a high-er dose to be more effective, espe-cially in patients with dementia.5

ConclusionFor patients with dementia and fortheir caregivers, an in-depth assess-ment should be conducted beforetreatment for insomnia is pre-scribed. In fact, a number of elder-ly people who complain about hav-ing trouble sleeping have a physio-logic rhythm that is normal fortheir age. Education may reassurethose patients. Others suffer frominsomnia that is triggered or aggra-vated by poor sleep habits or bymedical or psychologic pathology.These patients may require phar-macologic treatment. People whodo not respond to either of thesetherapies may benefit from non-pharmacologic treatments includ-ing hypnotism.

Table 2

Medication that Can Interfere with Sleep• Anticholinergics• Antidepressants• Antihypertensives• Antineoplastics• Central nervous system stimulants

(e.g., caffeine and nicotine)• Corticosteroids• Decongestants• Diuretics• Antihistaminics• Respiratory stimulants


References1. Groulx B: Elderly Sleep Disorders and

Alzheimer’s Disease. The CanadianAlzheimer Disease Review, 1998; 3(2), 4-6.

2. Sadavoy J, Leclair K: Treatment of anxiety

disorders in late life. Revue canadienne depsychiatrie, 1997; 42(suppl. 1), 28S-33S.

3. Gillin JC, Byerley WS: The diagnosis and mana-gement of insomnia. N Engl J Med, 1990; 322,239-48.

4. Herrmann N: Pharmacotherapy of BehavioralDisturbances in Dementia. The CanadianAlzheimer Disease Review 1998; 2(2), 6-8.

5. Okawa M: The treatment of sleep disorder ofolder people. Sleep, 1991; 14, 169-77.

An emotional disturbance canalso be dealt with in another

way, not by clarifying it intellectu-ally but by giving it visible shape.Patients who possess some talentfor drawing or painting can giveexpression to their mood by meansof a picture. It is not important forthe picture to be technically or aes-thetically satisfying, but merely forthe fantasy to have free play andfor the whole thing to be done aswell as possible.1

The above quote by Carl Jung isvery fitting to the art therapy tech-nique and other modalities of inter-vention for the older adult, particu-larly those with dementia. Art ther-apy can help reduce anxiety, pro-vide meaningful activity, encour-age interaction with others, lessenisolation and marginalization, andultimately provide a better qualityof life and vital involvement in oldage.1-3 Meaningful recreationalactivities are therapeutic, and atrained art therapist can implementsuch a program.

Collage, free association paint-ing and theme-related drawingsfacilitated by an art therapist arequite different from the traditionalarts and crafts activities offered intherapeutic recreation programs.The emphasis is on process, notproduct, and the resident does all ofthe artwork him or herself. This isbased on the fundamental premisethat honors the creative process ofthe individual.

One activity of art therapy issandtray, sometimes referred to assandplay. Using a box with dimen-sions averaging 28” x 20” x 4”deep, filled with sand, participantsare given a choice of objects froman assortment collected and provid-ed by the therapist. These objectsrepresent achetypes, animals, build-ings, the four elements, nature etc.Participants then create a picturewithin sandtray. This approach hasevolved from theories put forth bypsychoanalysts Carl Jung,4 MargaretLowenfeld5 and Dora Kalff.6 It hasbeen used as a psychodynamic

Art Therapy: AnIntervention for Peoplewith Alzheimer’s diseaseArt therapy can help reduce anxiety, provide meaningfulactivity, encourage interaction with others, lessen isolationand marginalization, and ultimately provide a better qualityof life and vital involvement in old age.

by Elizabeth M. Ginn, BFA, BA, Graduate Diploma

Elizabeth M. Ginn, BFA, BA,Graduate Diploma is currentlyworking on her MA in ArtTherapy at Marylhurst Universityin Portland, Oregon. She is aformer arts administrator,curator and is a practising artistfrom Edmonton, Alberta.


approach to therapy with children,families, youth at risk, trauma sur-vivors, adults and seniors, and is par-ticularly successful for people withdementia. Regression through thetransitional object7 and the process ofplay allows elderly people withAlzheimer’s disease (AD) to experi-ence an activity that was meaningfulin their formative years.

Using Sandtray in a Long-term Care FacilitySandtray can be used as an interventionor diversion with residents in a long-term care facility (LTC). It is suitablefor people at any level of cognitivefunctioning, and is especially success-ful with people with dementia of theAlzheimer type. In sandtray, residentsare able to use the creative process toreminisce, reflect and project. Theexploration of creativity and the

process of creating little “worlds” outof objects allow residents to pass timein a constructive manner.

Residents in LTC facilities are notalways comfortable in or familiar withgroup activities. To implement the pro-gram, new activities can be in a smallgroup (ideally with four to six partici-pants) or on a one-on-one basis.Because of staff shortages and bud-getary restrictions, this is not alwayspossible. Volunteers therefore play aconsiderable role in enabling the socialinteraction of residents. Staff membersand volunteers must receive training insandtray; the world technique is crucialto its success. The experience of work-ing with objects within the sandtraymilieu can be very positive for peoplewith AD.

One of the most important aspectsof sandtray is allowing residents toselect their own objects; choosing

objects for them or suggesting what touse defeats the purpose. Passive partic-ipation is also therapeutic; looking ator holding objects can stimulate partic-ipants and result in changed behavior.Ultimately, it all becomes part of ameaningful activity that allows peopleto remain involved even in old age.2

References1. Jung C: The collected works of Carl

Jung. Routledge: London, 1959.2. Rubin J: Approaches to art therapy.

Bristol, PA: Brunner/Mazel, 1987.3. Erickson E, et al: Vital involvement in

old age. W.W. Norton & Co.: New York,1976.

4. Jung C: Memories, dreams andreflections. Random House: New York,1961.

5. Lowenfeld M: The world technique.George Allen & Unwin: London,1979.

6. Ammann R: Healing andTransformation in Sandplay. OpenCourt Publishing: Chicago, Ill, 1991.

7. Winnicott DW: Playing and reality.Basic Books: New York, 1975.

Group from the Venta NursingHome, Edmonton, Alberta paintingobjects from the ocean. May 1999.

Artwork by Venta residents. Top: paintings by 94 year old and 87 year oldresidents. Bottom: a free association painting by an 80 year old AD patient. A plastiscene and color pencil design by a 94 year old AD patient.


The Systematic Research Overview Pilot Project, underthe auspices of the Alberta Heritage Foundation forMedical Research (AHFMR) Dissemination Program,was initiated early in 1997. The objective of the pilotproject was to synthesize and assess research findingsthat address a question of concern to members of theAlberta Association of Registered Nurses. The selectedresearch question was “What strategies are effective inmanaging the difficult behaviors associated with demen-tia of the Alzheimer type in elderly individuals?”

Characteristics of the Relevant ArticlesThe search strategies resulted in 265 articles. Forty-fiveof the articles met all of the established relevance crite-ria. The interventions examined in the studies include:music, which was the most frequent intervention, fol-lowed by skill training and visual barriers. The remain-ing interventions were exercise, pet therapy, sensoryintegration, bright light therapy, reality orientation, pres-ence, life review, hand massage, therapeutic touch, andwhite noise. The most commonly addressed behaviorsthat pertained to the purpose of this overview were:social interaction, wandering, agitation, self-care activi-ty, physically violent behavior, vocally disruptive behav-ior, day/night disturbances, and eating problems. For thepurpose of this article, only aggressive, agitated and dis-ruptive behaviors are examined.

Aggressive, Agitated, and Disruptive BehaviorsOne of the most difficult behaviors to manage isaggressive, agitated, and disruptive behaviors. Staff,with already heavy workloads, must deal not only withthe agitated resident but also attempt to calm other res-idents disturbed by the noise and activity. In managingthese behaviors, several strategies showed promise.

A planned walking program was conducted immediatelyafter the evening meal, three times a week. Two to threevolunteers walked with eleven participants through pub-lic areas for 1.5 hours. The walking program was effec-tive in reducing the number of aggressive events by 30%on a dementia special care unit.1

Simulated presence therapy is based on the belief thatthe primary and most central source of stability for anindividual with AD is often an informal caregiver, usual-ly a family member. A personalized audiotape composedof a family member’s telephone conversation of cher-ished memories was played for 27 residents when theydisplayed a problem behavior. The nursing staff record-ed whether the resident’s behavior improved, remainedunchanged, or worsened in response to the simulatedpresence therapy. Positive responses were demonstratedby 81% of the subjects. Among the behavior problemsnoted, simulated presence therapy appears most effectivein treating social isolation (84%) and agitation (78%).2

Another advantage of simulated presence therapy is thatimportant aspects of the residents’ past become apparentto the staff. For example, information about residents’hobbies, interests, and family members may be revealedon the audiotape which provides insight into the resi-dents’ personalities.

Exposure to bright light treatment was examined inrelation to reducing agitation in six moderately andseverely demented elderly residents of a nursing home.3

A light box was placed approximately one metre awayfrom the resident at a height within the resident’s visualfield between 9:30 a.m. and 11:30 a.m. for two 10-dayperiods. Agitated behavior was rated once every 15 min-utes between 4:00 p.m. and 8:00 p.m. Less agitation wasobserved on treatment days. It is interesting to note thathigher initial agitation resulted in lower agitated behav-ior with exposure to light. However, all but one resident’sagitated behavior had returned within two days follow-ing the treatment.


Challenging Behaviors in Alzheimer’s Disease: What Do We Know?by Dorothy A. Forbes, RN, PhD

News from the AlzheimerSociety of Canada

Dorothy A. Forbes, RN, PhDAssistant Professor, College of Nursing.


Twenty agitated long-term care facility (LTCF) resi-dents were exposed to 15 minutes of classical, calmingmusic on two occasions, one week apart. The residentswere assessed for level of agitation for 15 minutesbefore, 15 minutes during, and 15 minutes after themusical intervention. There was a reduction in agitatedbehavior both during and after the musical was played.4

In another similar study, classical and favorite musicwas found to decrease the number of repetitive disrup-tive talking in two of three LTCF residents with AD.The third resident showed little decrease in agitatedbehavior, which may be related to the individual notfinding classical music relaxing.5

Another study examined ways of dealing with therepetitive questions or statements of some elderly individ-uals with AD. This was the only study included in theoverview that measured the effectiveness of an interven-tion in the home. There is a great need for further researchin this area as informal caregivers are desperate for inter-ventions that lessen their stress in managing their lovedones at home. Seven caregivers who received a behaviormanagement intervention were compared with anothergroup of seven caregivers. Caregivers in the interventiongroup were instructed to implement a written cueing sys-tem. The cues consisted of answers to repetitive questionsor statements in simple phrases printed on index cards. Thefindings revealed that informal caregivers’ use of writtencues was effective in decreasing repetitive talking.6

LimitationsBecause of the lack of a randomized design in many ofthe studies, the effect of attention could not be controlled.Consequently, the positive effect reported in many of thestudies may be caused, in part, due to the attention thatthe subjects received by engaging in the activities. Thefindings of this overview must be considered in light ofthe methodological limitations that were found in all ofthe studies included.

Implications for PracticeAlthough the studies varied in their strength ofresearch design, all of the reported strategies are felt tobe worth trying as the overview has revealed the bestavailable scientific evidence for managing the behav-ioral symptoms of individuals with AD. The strategiesare clinically safe and most can be easily implementedin a wide variety of settings: acute care, long-term care,

adult day care, and home care. Although the interven-tions were occasionally implemented by the researcheror by individuals with specialized training, most care-givers could use these strategies when caring for indi-viduals with AD.

Implications for ResearchReplication of studies with individuals who are diag-nosed with a variety of dementias and with differentlevels of cognitive impairment are recommended todetermine which strategies are appropriate for the var-ious dementias and levels of impairment. Longitudinalstudies are needed to assess the effectiveness over peri-ods of time in preventing or delaying the progression ofthe disease and in reducing caregiver stress. The cost-effectiveness of implementing the interventionsrequires further study and would be of particular inter-est to policy makers and administrators.

References1. Holmberg SK: Evaluation of a clinical intervention for

wanderers on a geriatric nursing unit. Arch Psychiatr Nurs,1997 11(1), 21-8.

2. Woods P, Ashley J: Simulated presence therapy: Using selectedmemories to manage problem behaviors in Alzheimer’s diseasepatients. Geriatric Nursing, 1995, 16(1), 9-14.

3. Lovell BB, Ancoli-Israel S, Gevirtz R: Effect of bright lighttreatment on agitated behavior in institutionalized elderlysubjects. Psychiatry Res, 1995, 57, 7-12.

4. Tabloski PA, McKinnon-Howe L, Remington R: Effects ofcalming music on the level of agitation in cognitivelyimpaired nursing home residents. Am J Alzheimer’s Care andRelated Disorders & Research, 1995, 10-15.

5. Casby LA, Holm MB. The effects of music on repetitivedisruptive vocalizations of persons with dementia. Am JOccup Ther, 1994, 48, 883-9.

6. Bourgeois MS, Burgio LD, Schulz R, et al: Modifyingrepetitive verbalizations of community-dwelling patients with AD. Gerontologist, 1997, 37(1), 30-9.

AcknowledgmentsThis piece is an excerpt from Dr. Dorothy Forbes’presentation at the Alzheimer Society of Canada’s 21st annualconference, 1999 in Ottawa, Ontario. Dr. Forbes’presentation was based on her study: Strategies to Managethe Behavioral Symptomatology Associated with SDAT: ASystematic Overview (Canadian Journal of Nursing Research,vol. 30, no.2, 67-86.) This research was gratefully funded bythe Alberta Association of Registered Nurses, the AlbertaHeritage Foundation for Medical Research, and the Faculty ofNursing, University of Alberta.

For more information on Alzheimer disease, please callyour local Alzheimer Society, look on the Internet at www. alzheimer.ca or call 1-800-616-8816.

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