Online Programme “Symparastasi”: Psychoeducation and Multicomponent Exercise Programme to the Caregivers of Patients with MCI and Mild Dementia: An Original RCT

Tatiana Danai Dimitriou^1* and Evangelia Zacharia^2
*Correspondence: Tatiana Danai Dimitriou, Department of Neurology, International Hellenic University, 44 Salaminos str., Halandri, Attica 15232, Greece, Tel: +0030 6978113357, Email:

Keywords

Dementia caregivers • Non-pharmacological interventions • Psychoeducation • Cognitive abilities

Abbreviations

ACE-R: Addenbrooke’s Cognitive Examination (revised); AD: Alzheimer’s Disease; BDI: Beck Depression Inventory; BPSD: Behavioural and Psychological Symptoms in Dementia; CDR_SB: Clinical Dementia Rating scale; CVD: Cardiovascular Dementia; DLB: Lewy Body Dementia; FTD: Frontotemporal Dementia; MCI: Mild Cognitive Impairment; MMSE: Mini Mental State Examination; NPI: Neuropsychiatric Inventory; PDD: Parkinson’s Dementia; PwD: Patients with Dementia; RCT: Randomized Controlled Trial; STAI-S: State Trait Anxiety Inventory; ZBI: Zarit Burden Interview

Introduction

Dementia is a syndrome and an umbrella term characterized by cognitive declines [1]. There are many diseases that may cause non-reversible dementia, but the most common disease is Alzheimer's Disease (AD), following by Cardiovascular disease (VaD), Lewy Body Dementia (DLB), Parkinson’s dementia (PDD) and Frontotemporal Dementia (FTD) [2]. Dementia is the seventh leading cause of death and until now there is no cure [3]. It is a disease that mainly affects people aged over 60 years old [1]. Dementia affects all cognitive abilities including memory, learning, attention, concentration, language, social recognition, executive function, and motor perception. Therefore, it affects the patient in his/ her daily activities [1]. There are nowadays 50 million people with dementia globally. The number is estimated to increase to 152 millions in the next 25 years [3]. Dementia affects not only the patients but their families and the economy, as well. The global costs of dementia are estimated at approximately 1 trillion US dollars annually [4].

Mild Cognitive Impairment (MCI) may lead to dementia and therefore because of its potentially progressive character it is called as a pathological condition [5]. The main difference between MCI stage and dementia is the daily functioning of the patient. Patients in MCI stage may live independently, although they have several cognitive problems, but dementia patients have such cognitive problems that are unable to live independently [5]. Disease progression has as a start MCI and spans in different stages to mild, middle and severe stages of dementia.

Behavioral and Psychological Symptoms of Dementia (BPSD) are among the earliest signs and symptoms of dementia. They affect approximately the 90-95% of the Patients with Dementia (PwD) [6]. Their severity increases over the course of the disease. BPSD also called as neuropsychiatric symptoms and are associated with many negative outcomes, such as functional impairment and faster cognitive decline. Furthermore, neuropsychiatric symptoms may increase risk for secondary complications, such as earlier institutionalization, falls and fractures [7]. The etiopathogenesis of BPSD remains complex and therefore their cure is difficult. It is probably a result of multiple factors, such as biological, psychological and social factors [8]. According to Cummings JL, et al. [9] there is 12 different BPSD: delusions, hallucinations, agitation/ aggressive behaviour, depression, anxiety, euphoria, apathy, disinhibition, irritability, wandering, sleeping problems and eating disorders. There are some pharmacological solutions, such as antipsychotics, antidepressants etc., that aim to decrease the frequency or the severity of the BPSD, but they have severe side effects such as confusion, hearth arrhythmia, constipation, dizziness, headaches, xerostomia, fatigue, and gastrointestinal problems [10].

As there is no cure for dementia nowadays and the medicine used for the treatment of BPSD have severe side effects it is crucial to mention the importance of non-pharmacological solutions. According to the literature so far there are numerous of studies that have examined the effect of several non-pharmacological interventions in BPSD and their outcomes were very promising [11-13]. Two beneficial non-pharmacological interventions are Psychoeducational programmes and Multi component physical exercise. Psychoeducational programmes either online or face to face have promising results in increasing the quality of life of the patients and their caregivers, as well [14]. These programmes aim to educate the informal caregivers in order to provide them with serious information about the progress of the disease, the possible problems that may occur and the optimal ways in order to manage some problems in dementia. Most of the informal caregivers find the programmes useful [14]. Sometimes informal caregivers do not know how to manage some problems and therefore this causes them stress and depression. Caregivers also called as “second patients” because their anxiety depression levels are higher than other people in their age that are not caregivers [15]. Dementia caregivers often say that they do not have personal time, they experience social isolation and have problems with their sleeping schedule [15]. Hence, it is very important to consider the quality of life of the caregivers, too. Although the programs may differ from one another their main goal is to educate the caregivers in order to make them more useful to their patients and themselves. On the other hand, physical exercise has been examined in numerous of studies which have underlined its importance in preventing dementia and managing some BPSD [16,17]. Multi Component physical exercise includes exercises for flexibility, strength, stamina and endurance. Individuals who consistently exercise have significantly benefits in mood improvement, reduction of depression symptoms, brain plasticity and neurotransmitters’ production [18]. According to recent literature studies multicomponent exercise combines physical components (resistance training and cardiovascular training) and motor components (balance, reaction time and dual exercises, co-ordination) and this is why it is very beneficial to the PwD [19,20]. In addition, multicomponent exercise has also been proven positive in enhancing the general mood and psychology of PwD and their caregivers, too [21].

The current study aims to find which group out of these three, a) participants who only receive multicomponent physical exercise, b) participants who only receive psychoeducational programme and c) participants who receive both interventions have better results in the following three domains: 1) maintaining or increasing the cognitive abilities, 2) decrease BPSD, and 3) increase the quality of life of the patient and the caregiver, as well.

Methods

Design

This is a randomized controlled trial. A total of 426 (N=426) PwD and their caregivers were randomly assigned into 3 different groups. Group A received only the multi component exercise program, Group be received only the psycho educational program, and group she received both interventions. Participants who had motor problems were automatically assigned to group B. Patient and participants have given written consent and all their data remained confidential. All patients were suffered from MCI or mild dementia.

They were recordings of the scales at the beginning of the programme, before any intervention occurred (T1). After six months of receiving the intervention the same scales were also applied and recorded (T2). Then all the interventions stopped and three months after we also applied and recorded the same scales (T3), in order to see if the results maintained over time.

Subjects

The study included participants of both genders and their participants who necessarily had access to the Internet and knew how to use a computer. In order to diagnose the participants some scales were used. For the cognitive abilities we used the Addenbrrokee’s Cognitive Examination Revised test (ACE-R), which includes Mini Mental State of Examination (MMSE) and for the daily functioning we used the CDR_SB scale.

Measurements

The following measurements were used in order to identify the cognitive abilities of the PwD: a) MMSE and b) ACE-R. These two scales are very accurate and higher scores indicate better performance. MMSE is included in ACE-R test. The scales aim to score the following cognitive abilities; memory, language, attention, concentration, fluency, and visuospatial ability of the PwD. For measuring the daily functioning of the PwD we used Clinical Dementia Rating–Sum of Boxes (CDR_SB) scale. For the BPSD we used Neuropsychiatric Inventory (NPI). For measuring the caregivers, we used several scales: State Trait Anxiety Inventory (STAI-S) in order to record the anxiety levels, Beck Depression Inventory (BDI) for the depression and NPI and Zarit Burden Interview (ZBI) in order to record caregivers’ burden. For the multicomponent exercise programme we used the following scales: Timed Up and Go test (TUG) was used to estimate functional mobility and fall risk. Participants were instructed to stand up from a chair, walk as fast as possible for 3 meters, then turn, walk back to the chair and sit down. Additionally, for assess balance ability; the Berg Balance Scale (BBS) was performed. The BBS is the best-known balance measurement tool and it consists of qualitative measures in several postural and every day movements. Each item is scored according to a 5-point scale, from 0 (which indicates the lowest level of function) up to 4 (which indicates the highest level of function). Nagging from 0 to 4 (in which 0 indicates the lowest level of function and 4 indicates the highest level of function). The total possible score is 56 points, and 41–56 suggests a low fall risk, 21–40 a medium fall risk and 0–20 a high fall risk. Muscle strength, measured by a 30 second Sit to Stand Test. The participants were asked to stand up and sit down for a high armless chair as many times as possible during a 30 sec phase.

Interventions

Programme “Symparastasi” was created during the quarantine due to COVID-19 in order to help the patient and the caregivers who then did not have access to the third age centers. When the quarantine stopped the importance of a programme that could provide with knowledge and useful information the caregivers and offer them solutions in their daily problems remained. There are several patients who live away from the big city centers and therefore they do not have access to professional care. Hence, an online programme which could offer them knowledge, psychological support and accurate and safe solutions to their problems seemed to be a solution. First of all, we created a platform (https://symparastash.web.app/#/home). We included in the platform all the above mentioned scales. Then by advertising our programme over the social media and from mouth-to-mouth we collected the sample-participants.

The neuroscientist and the fitness specialist created 12 different videos each (total of 22 videos) for their lessons. The duration of each video was from 15 to 20 minutes. The lessons of the psychoeducational programme had the following structure: a) theoretical background and b) practical solutions. In the first part of theoretical background the neuroscientist talked about dementia, its prognosis, BPSD, other daily problems, prevention, nutrition and other aspects of the disease. In the second part of the practical solutions the neuroscientist offered non-pharmacological interventions for managing some BPSD and other daily problems. The neuroscientist taught the participants how to perform music therapy, aromatherapy, massage therapy, orientation therapy, validation therapy, reminiscence therapy, behavioural techniques and other non-pharmacological interventions that have been proven beneficial according to the literature so far. In particular, according to the literature so far, the music therapy was performed for 45’ every day [22,23]. Aromatherapy in combination with massage therapy was applied in the arms, shoulders, back and wrists of the PwD for 10-20’ and lemon oil and levander were used [24,25]. Orientation and validation therapy was used every day for 45’ [26,27]. Reminiscence therapy was performed for 45’ every day and photo albums and videos were used in order to help the patient recall past and positive memories [28]. Behavioural techniques included proper communication with the PwD, useful and meaningful activities such as gardening together, cooking together, watch a movie together, etc [29]. On the other hand, the fitness specialist started each video with a warm-up, then explained the main exercises by showing how to perform them safely and effectively, and at the end of each video the fitness specialist was showing exercises for cooling down in order to avoid any injury. There was a difficulty progression in the videos.

The caregivers had access to the data by using their username and password that the web developer gave them. A new video was released every two weeks. The participant could not see the next video unless the two weeks had passed. In the time of these two weeks the caregiver should apply to the PwD the interventions taught in the lesson. The 12^th lesson was an online private session with the neuroscientist and the fitness specialist. In this session the caregiver and the patient could ask any question and be supported emotionally and independently. During the whole period of the interventions that lasted for 24 weeks (6 months) the participants and the patients could access the tutors by email, phone call, or video call. We had to ensure that the caregivers had understood how to perform the interventions and all the interventions were applied safely to the caregivers. The programme did not aim under any circumstance to replace the formal caregivers and the third age centers. However, it is critical to consider people who live away from the big city centers and do not have access to this kind of care. They should be also provided with the optimal services and they should be able to manage dementia and it's progression with safe solutions and effectively.

Results

A total of 426 PwD and their participants were included in the study. 142 participants in each of 3 groups. 221 participants were females (51.8%). Group A, which received only the multicomponent exercise programme had a mean score of 71.9 years old (SD 4.55), and 9.51 years of education (SD 3.78). Group B which received only the psychoeducation had a mean score of 71.5 years old (SD 4.64) and 9.42 years of education (SD 3.29), and group C which received both interventions had 73.8 years old (SD 3.79) and 7.78 years of education (SD 3.57). Table 1 shows the demographics of the sample. According to the results statistically significant changes were showed in MMSE in T3 test in all groups, which means that the interventions had a positive impact on the cognitive abilities over time. However, in ACE-R scale group C had statistically significant changes in T2 test, but could not maintain the good results in T3 test. All groups decreased the BPSD, according to the NPI scale. Group C had the best results of all other groups. The same result applied in NPI scale for the caregivers, as well. In particular, all groups decreased caregivers’ burden, but only group C had the best results in T3, which means that they maintained the beneficial effects. Group A and group B could not maintain their good results in CDR_SB scale, but group C had a statistically significant difference. In BDI test only group C maintained the good results in T3 but all groups had statistically significant reductions. The same result applied in ZBI test, as well. Group A and C maintained the good results in T3, but group B also had a statistically significant reduction of ZBI test in T2. Lastly, group C had the best result in STAIS scale, but all groups reduced STAIS in T2, as well. Tables show all the scales and their results analytically (Tables 2-39 and Figures 1-8).

Discussion

According to the results group C, which received both the multicomponent training programme and the psychoeducation had the best results in three domains: a) increased the cognitive abilities, b) decreased BPSD, and c) enhanced the general quality of life of the PwD and the caregivers, too. It is important to mention that all groups had positive results in all scales, which means that both these non-pharmacological interventions have beneficial effects in PwD and their caregivers. However, the combination of multicomponent exercise and psychoeducation has better results in T2 and T3. This is crucial because it is important to find interventions that can last over time. Nevertheless, in some cases the good results did not maintain over time, which means that in order to have the best outcomes of the interventions it is recommended to be applied in a daily or weekly schedule.

Furthermore, group A and B did not show any statistically significant change in T2 period of ACE-R test. However, the result is not disappointing. It is important to maintain the cognitive abilities of the PwD, when it is not possible to enhance them. Therefore, the result that group A and B in T2 period of ACE-R showed that the interventions maintained the good cognitive abilities of the participants. For the cognitive abilities it seems that if the interventions stop, then the cognitive declines are coming. None of the groups could maintain the good outcomes in T3 period, which means that we have to give feedback to our patients constantly. On the other hand, all groups decreased BPSD, according to the NPI scale. Group C had the best results, which means that the combination of the two non-pharmacological interventions had the best outcomes in decreasing some BPSD. According to our results, the total score of NPI was decreased in all groups, but only group C maintained the good results over time. Our results are in accordance with previous studies. Numerous studies have shown that physical exercise can effectively reduce some BPSD, such as wandering, depression, anxiety and agitation [16,30-33]. At the same time, several studies have shown that psychoeducation can provide the caregivers with useful knowledge in order for them to be able to manage BPSD [34]. Our programme aimed to give solutions to the daily behavioural problems of the PwD and also explain how to control all BPSD with non-pharmacological solutions, according to previous studies that have shown beneficial results [34]. Lastly, only group C maintained the good results in CDR_SB scale, which means that the daily functioning of the PwD could maintain over time if they had previously received both interventions. However, it is critical to mention that group A and B also helped the participants to enhance their daily functioning in T2 period.

In terms of the caregivers, the results are also interesting. BDI scale showed that all groups decreased the depression levels of the caregivers in T2 period, but only group A and especially group C maintained better the results. Caregivers experience levels of anxiety and depression, because of the caregiving [15,35]. Caring a PwD is sometimes a full time job, which requires of the caregiver to give most of his/ her time, money and personal well-being. According to the literature the caregivers often suffer from physical and emotional problems [36]. Therefore, it is important to find interventions that can effectively enhance the well-being of the caregivers. Moreover, ZBI test showed positive results in all groups, however only group A and C maintained the good results over time. This is crucial because it seems that physical exercise when applied daily for 6 months in a row can maintain a promising low level of burden in the caregivers. In addition, STAIS scale also pointed that all groups decreased the anxiety levels of the caregivers. Best results were found in group C, which means that the combination of the interventions had the best outcomes for the caregivers.

Considering the fact that there is no cure for dementia and the current pharmacological solutions have severe side effects, as mentioned above, it is critical to find non-psychological interventions that can effectively maintain the cognitive abilities of the patient, decrease BPSD, and enhance the quality of life of the patient and the caregiver too. Therefore it is remarkable that we found combination of non-pharmacological solutions that can effectively be applied to the patient from the caregivers and also have a positive outcome in those three domains that are very essential in this disease.

In addition, according to a recent review which included all the original studies that have combined the psychoeducation programme with a multicomponent training programme, our results seem to be in accordance with most of these results. The first trial of Skov SS, et al. [37] used an intervention with two weekly training sessions. Their intervention lasted for 15 weeks and the duration was three hours per session. The study had 7 -10 participants and the programme also included 1.5 hour physical exercise which was combined with either one hour of CST or either one hour of psychoeducation. This is a trial that took place in Copenhagen and the sample was consisted from 44 participants. The study used scales as; MMSE, and Quality of Life in Alzheimer’s Disease (QoL-AD). The training session was applied by two psychotherapists in a workout room and they included warm-up, cycling, short breaks and strength exercises. On the other hand, the psychoeducational programme lasted for one hour and included themes about dementia. The trial concluded positive results of the combination of the psychoeducation and physical exercise.

Moreover another study with a follow-up test which included 57 patients and 54 participants in a comparison group took place in the Netherlands and included a personal trainer with eight sessions lasted one hour for three months and additionally the training program included exercise for balance flexibility strength and endurance [38]. Educational program aim to give the caregivers knowledge and encourage communication between them and their patients. The programme did not find significant differences in executive functions, but on the other hand it is important that the trial reported positive outcomes in terms of attention. In addition, according to the results of another study which examined the combination of education and multi component training program and had a large sample size of 255 participants, found promising results after the combination of the psychoeducation and the physical exercise. The psychoeducation programme included topics about dementia and the programme lasted for four months. It is very important that this trial underlined that the beneficial results maintained after 13 months after the end of the programme [39]. However, the trial does not mention which measurements used in order to identify its results. Additionally, the last study examined the combination of psychoeducation and physical exercise and took place in 2020 [40]. The sample size was consistent of 153 participants who received the psychoeducation programme for two hours, for six times, and there was another group received psychoeducation with exercise for a minimum of 30 minutes and there was also the attention control group focused on some aspects of dementia and also performed stretching exercises and flexibility. The trial used PROMIS emotional distress-depression instrument for measuring the depressive symptoms and also ZBI scale for the caregivers’ burden. However, this study in contrary with our results did not mention significant differences in caregivers’ distress.

Nevertheless, the previous studies have used (some of them) quiet large sample sizes, however they do not report which measurements scales used for the cognitive and physical tests of the sample. It is also not clear in some cases how frequently the interventions were taken place. On the other hand, none of the above-mentioned trials did not aimed to examine the effect of the combination in the three domains: a) cognitive abilities, b) BPSD and c) quality of life of both patient and caregiver.

Our study has some strengths. We have a large simple size, a strict methodology, we applied the psychoeducational programme as the literature has pointed, we performed the non-pharmacological interventions in a way that the literature so far has mentioned that is most beneficial, we had specialists to perform the videos, we used many scales in order to measure several aspects of the disease, we had quite large duration of our interventions and we had a follow up test. All groups received a very strict, analytical, and clear protocol of how to perform every intervention and at any time of the performing period the informal caregivers could speak with a specialist and be sure that they apply the interventions effectively and safely. The duration of our interventions were in accordance with previous studies and the frequency, as well. Future studies should focus on large samples, strong methodology, extend the duration of the interventions, examine all aspects of the disease, not only the cognitive abilities or the neuropsychiatric problems, include how to decrease caregivers’ burden, and have follow up test, in order to identify if the good results can maintain over time [41-44].

Conclusion

It is very important to find a combination of non-pharmacological interventions that can effectively be performed by informal caregivers and help the patients maintain their cognitive abilities, decrease BPSD, and enhance the general quality of life of the patient and the caregiver, as well. Non-pharmacological interventions should be well researched, because the literature so far mentions promising results. Patients and caregivers who live away from the big city centers and they cannot have access to formal care, should not be ignored. Online programmes can effectively replace the face-to-face meetings and offer to the PwD and their caregivers a professional care, despite the distance. Informal caregivers should be well trained in order to be aware of the disease, know what to expect, have realistic expectations and help their patients and themselves in an effective and right way. Online programme “Symparastasi” gave the opportunity to the informal caregivers to be fully trained on dementia and multicomponent exercise, in order to be able to communicate better with their patients and be better caregivers. It is crucial that the participants mentioned that they enjoyed the programme, and we did not have dropouts, or any injury from the training programme, which means that if the caregivers listen carefully to the videos and perform strictly by the book all the advices, several interventions can be effectively be applied by them.

Acknowledgement

None.

Conflict of Interest

The authors declare no conflict of interest.

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