Neuropsychological rehabilitation program and behavioral disturbances in early-stage Alzheimer patients

Vieira, Vera Lúcia Duarte; Brucki, Sônia Maria Dozzi; Martins, Anna Luiza Costa Marques; Canali, Fabíola; Gois, Luciano; Oliveira, Maira Okada de; Bittencourt, Beatriz Schlecht; Leite, Lúcia Julieta Tonato; Abrisqueta-Gomez, Jacqueline; Bueno, Orlando Francisco Amodeo

doi:10.1590/S1980-57642009DN20200012

Abstract

Alzheimer's disease (AD) is the most frequent cause of dementia and cholinesterase inhibitors are the available treatment in the mild stage. However cognitive rehabilitation has shown satisfactory results when combined with pharmacological treatment. Behavioral alteration is common in AD patients, which burdens caregivers and raises the risk of institutionalization. Providing caregivers guidance may enable them to assure better quality of life for patient and caregiver and lower institutionalization rates.

Objective:

To evaluate the effects of a neuropsychological rehabilitation program (NRP) combined with pharmacological treatment in early stage AD patients.

Methods:

We studied 12 AD patients (6 women), average age 75.42 (6.22) with 9.58 (5.6) years education in use of stable doses of cholinesterase inhibitors. Cognitive performance was evaluated using Mini-Mental State Examination (MMSE) and Alzheimer´s Disease Assessment Scale-cognitive (ADAS-Cog). Caregivers responded to Neuropsychiatric Inventory (NPI) and Functional Activities Questionnaire (FAQ) at initial evaluation (T1), and after 8 months of rehabilitation program (T2). The program comprised two sessions every week and family guidance every fortnight.

Results:

MMSE (T1:23.25 (1.82)/T2:23.42 (2.81); ADAS-Cog (T1:17.11 (6.73)/T2:21.2 (8.59); NPI (T1:23.42 (23.38)/T2:19.83 (17.73); FAQ (T1:10.67 (7.24)/T2: 13.92 (6.92).

Conclusions:

These results show the importance of providing guidance and support for caretakers. Study limitations were the small number of patients and absence of a control group with only drug treatment to compare with combined pharmacological and rehabilitation treatments.

Key words:
dementia; caregivers; behavioral disorders; non-pharmacological interventions

Resumo

A doença de Alzheimer é a demência mais freqüente, o tratamento disponível específico, no estágio leve é com droga anticolinesterásico. Por outro lado a reabilitação cognitiva tem apresentado resultados satisfatórios quando associado ao tratamento farmacológico. É comum alteração de comportamento em pacientes com DA, o que contribui para uma maior sobrecarga do cuidador aumentando o risco de institucionalização. Cuidadores orientados sobre a doença pode permitir uma melhor qualidade de vida para ambos diminuindo a taxa de institucionalização.

Objetivos:

Avaliar os efeitos de um programa de reabilitação neuropsicológica (PRN) associado ao tratamento farmacológico de pacientes em fase leve da DA.

Métodos:

12 pacientes com DA (6 mulheres) com idade média de 75.42 (6.22) e 9.58 (5.6) anos de escolaridade e dose estável de anticolinesterásicos foram avaliados com o Mini-Exame do Estado Mental (MEEM) e Alzheimer´s Disease Assessment Scale-cognitive (ADAS-Cog) e os cuidadores responderam NPI e FAQ na avaliação inicial (T1) e depois de 8 meses do PRN (T2). O PRN foi composto por duas sessões semanais e Orientação Familiar a cada 15 dias.

Resultados:

MMSE (T1:23.25 (1.82)/T2: 23,42 (2,81); ADAS-Cog (T1:17.11 (6,73)/T2: 21.2 (8,59); NPI (T1:23,42 (23.38)/T2:19.83 (17,73); FAQ (T1:10,67 (7.24)/T2: 13,92 (6.92).

Conclusões:

Estes resultados nos mostram a importância do trabalho desenvolvido com cuidadores, propiciando orientação e suporte. Limitações aos resultados podem estar presentes pelo número reduzido de pacientes, ausência de um grupo controle que permitisse a comparação do tratamento farmacológico isolado com tratamento farmacológico e reabilitação em conjunto.

Palavras-chave:
demência; cuidadores; distúrbios de comportamento; intervenção não-farmacológica

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References

¹
Cummings L, Frank JC, Cherry D, et al. Guidelines for managing Alzheimer disease: Part II. Treatment. Am Fam Physician 2002;65:2525-2534.
²
Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Diagnosis of Alzheimer's disease in Brazil: cognitive and functional evaluation. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Arq Neuropsiquiatr 2005;63:720-727.
³
Abrisqueta-Gomez J, Canali F, Vieira VLD, et al. A Longitudinal study of a neuropsychological rehabilitation program in Alzheimer disease. Arq Neuropsiquatr 2004;62:778-783.
⁴
Ávila R. Reabilitação neuropsicológica dos processos de mémoria e das atividades da vida diária em pacientes com doença de Alzheimer leve e moderada. Dissertação. Faculdade de Medicina da Universidade de São Paulo, São Paulo; 2004.
⁵
Wilson BA. Reabilitação das deficiências cognitivas. In: Nitrini R, Caramelli P; Mansur LL, editors. Neuropsicologia das Bases Anatômicas à Reabilitação. São Paulo, Clinica Neurológica HC-FMUSP;1996:314-343.
⁶
Tariot PN, Blazina L. The psychopathology of dementia. In: Morris JC, editor. Handbook of dementing illnesses. New York: Marcel Dekker Inc.; 1994.
⁷
Mega MS, Cummings JL, Fiorello T, Ggornbein J. The spectrum of behavioral changes in Alzheimer disease. Neurology 1996;46:130-135.
⁸
Folstein ME, Foltein SE, Mc Hugh PR. Mini Mental state, a practical method for grading the cognitive state of patients for the clinical. J Psychiatr Res 1975:12:189-198.
⁹
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Suggestions of utilization of the Mini-mental state examination in Brazil. Arq Neuropsiquiatr 2003:61:777-781.
¹⁰
Rosen WG, Mohs R,Davis M. A new rating scale for Alzheimer's disease. Am J Psychiat 1984: 141:1356-1364.
¹¹
Schultz RR, Silviero MO, Bertolucci PHF. The cognitive subscale of the "Alzheimer's Disease Assessment Scale" (ADAS-COG) in a Brazilian sample. Braz J Med Biol Res 2001:34:1295-1303.
¹²
Hindmarch JR, Lehfeld H, Jongh P. Dementia and geriatric cognitive disorders. In: Burns A, Lawlor B, Craig S, editors. Assessment scales in old age psychiatry. UK, Martins Dunitz; 1998:162.
¹³
Pfeffer RI, Kurosaki TT, Harrah CH, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.
¹⁴
Cummings JL, Jeffrey J. The neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology1997;48(suppl.6):S10-S16.
¹⁵
Teri L, Truax P, Logsdon RG, Uomoto J, Zarit S, Vitaliano PP. Assessment of behavioral problems in dementia: the revised memory and behavior problems checklist. Psychol Aging 1992;7:622-631.
¹⁶
Ávila R. Resultados da reabilitação neuropsicológica em pacientes com doença de Alzheimer leve. Rev Psiquiatr Clin 2003;30:139-147.
¹⁷
Bottino CMC, Carvalho IAM, Alvarez AM, et al. Reabilitação cognitiva em pacientes com doença de Alzheimer: relato de trabalho em equipe multidisciplinar. Arq Neuropsiquiatr 2002; 60:70-79.
¹⁸
De Vreese LP, Neri M, Fioravanti M, Belloi L, Zanetti O. Memory rehabilitation in Alzheimer's disease: a rewiew of progress. Int J Geriatr Psychiatry 2001;16:794-809.
¹⁹
Ferretti CEL, Bertolucci PHF. A enfermagem nas demências: uma visão multidisciplinar. J Bras Neuropsiquitr Geriatr 2001;2.
²⁰
Teri L, Longsdon RG, Schindler R. Treatment of behavioral and mood disturbances in dementia. Generations 1999;23:50-56.
²¹
Teri L, Longsdon RG, McCurry SM. Nonpharmacologic treatment of behavioral disturbance in dementia. Med Clin N Am 2002;86:641-656.
²²
Bougeois MS, Shulz R, Burgio L. Interventions for caregives of patients with Alzheimer"s disease: a review and analysis of content, process, and outcomes. Int J Aging Hum Dev 1996;43:35-92.
²³
Mckhann G, Drachman D, Folstein M. Clinical diagnosis of Alzheimer's disease: Report of the NINCDS-ADRDA Work Group under the auspice of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1989;34:939-944.
²⁴
Thompson CA, Spilsbury K, Hall J, Birks Y, Barnes C, Adamson J. Systematic review of information and support interventions for caregivers of people with dementia BMC. Geriatrics 2007;7:18.
²⁵
Longsdon RG, McCurry SM, Teri L. A community-based approach for teaching family caregivers to use behavioral strategies to reduce affective disturbances in persons with dementia. Gerontologist 2005;6:2:146-153.
²⁶
Perry RJ, Hodges JR. Attencion and executive deficits in Alzheimer's disease- a critical review. Brain 1999;122:3383-3404.
²⁷
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV) 4th ed. Washington,DC. American Psychiatric Association 1994.
²⁸
Teri L, McCurry SM, Logsdon R, Gibbons LE. Consultants to help family members improve dementia care: A randomized controlled trial. Gerontologist 2005;45:6:802-811.

Publication Dates

Publication in this collection
Apr-Jun 2008

History

Received
29 Apr 2008
Accepted
21 May 2008

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Cummings L, Frank JC, Cherry D, et al. Guidelines for managing Alzheimer disease: Part II. Treatment. Am Fam Physician 2002;65:2525-2534.

[2] ²
Nitrini R, Caramelli P, Bottino CMC, Damasceno BP, Brucki SMD, Anghinah R. Diagnosis of Alzheimer's disease in Brazil: cognitive and functional evaluation. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Arq Neuropsiquiatr 2005;63:720-727.

[3] ³
Abrisqueta-Gomez J, Canali F, Vieira VLD, et al. A Longitudinal study of a neuropsychological rehabilitation program in Alzheimer disease. Arq Neuropsiquatr 2004;62:778-783.

[4] ⁴
Ávila R. Reabilitação neuropsicológica dos processos de mémoria e das atividades da vida diária em pacientes com doença de Alzheimer leve e moderada. Dissertação. Faculdade de Medicina da Universidade de São Paulo, São Paulo; 2004.

[5] ⁵
Wilson BA. Reabilitação das deficiências cognitivas. In: Nitrini R, Caramelli P; Mansur LL, editors. Neuropsicologia das Bases Anatômicas à Reabilitação. São Paulo, Clinica Neurológica HC-FMUSP;1996:314-343.

[6] ⁶
Tariot PN, Blazina L. The psychopathology of dementia. In: Morris JC, editor. Handbook of dementing illnesses. New York: Marcel Dekker Inc.; 1994.

[7] ⁷
Mega MS, Cummings JL, Fiorello T, Ggornbein J. The spectrum of behavioral changes in Alzheimer disease. Neurology 1996;46:130-135.

[8] ⁸
Folstein ME, Foltein SE, Mc Hugh PR. Mini Mental state, a practical method for grading the cognitive state of patients for the clinical. J Psychiatr Res 1975:12:189-198.

[9] ⁹
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Suggestions of utilization of the Mini-mental state examination in Brazil. Arq Neuropsiquiatr 2003:61:777-781.

[10] ¹⁰
Rosen WG, Mohs R,Davis M. A new rating scale for Alzheimer's disease. Am J Psychiat 1984: 141:1356-1364.

[11] ¹¹
Schultz RR, Silviero MO, Bertolucci PHF. The cognitive subscale of the "Alzheimer's Disease Assessment Scale" (ADAS-COG) in a Brazilian sample. Braz J Med Biol Res 2001:34:1295-1303.

[12] ¹²
Hindmarch JR, Lehfeld H, Jongh P. Dementia and geriatric cognitive disorders. In: Burns A, Lawlor B, Craig S, editors. Assessment scales in old age psychiatry. UK, Martins Dunitz; 1998:162.

[13] ¹³
Pfeffer RI, Kurosaki TT, Harrah CH, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.

[14] ¹⁴
Cummings JL, Jeffrey J. The neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology1997;48(suppl.6):S10-S16.

[15] ¹⁵
Teri L, Truax P, Logsdon RG, Uomoto J, Zarit S, Vitaliano PP. Assessment of behavioral problems in dementia: the revised memory and behavior problems checklist. Psychol Aging 1992;7:622-631.

[16] ¹⁶
Ávila R. Resultados da reabilitação neuropsicológica em pacientes com doença de Alzheimer leve. Rev Psiquiatr Clin 2003;30:139-147.

[17] ¹⁷
Bottino CMC, Carvalho IAM, Alvarez AM, et al. Reabilitação cognitiva em pacientes com doença de Alzheimer: relato de trabalho em equipe multidisciplinar. Arq Neuropsiquiatr 2002; 60:70-79.

[18] ¹⁸
De Vreese LP, Neri M, Fioravanti M, Belloi L, Zanetti O. Memory rehabilitation in Alzheimer's disease: a rewiew of progress. Int J Geriatr Psychiatry 2001;16:794-809.

[19] ¹⁹
Ferretti CEL, Bertolucci PHF. A enfermagem nas demências: uma visão multidisciplinar. J Bras Neuropsiquitr Geriatr 2001;2.

[20] ²⁰
Teri L, Longsdon RG, Schindler R. Treatment of behavioral and mood disturbances in dementia. Generations 1999;23:50-56.

[21] ²¹
Teri L, Longsdon RG, McCurry SM. Nonpharmacologic treatment of behavioral disturbance in dementia. Med Clin N Am 2002;86:641-656.

[22] ²²
Bougeois MS, Shulz R, Burgio L. Interventions for caregives of patients with Alzheimer"s disease: a review and analysis of content, process, and outcomes. Int J Aging Hum Dev 1996;43:35-92.

[23] ²³
Mckhann G, Drachman D, Folstein M. Clinical diagnosis of Alzheimer's disease: Report of the NINCDS-ADRDA Work Group under the auspice of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1989;34:939-944.

[24] ²⁴
Thompson CA, Spilsbury K, Hall J, Birks Y, Barnes C, Adamson J. Systematic review of information and support interventions for caregivers of people with dementia BMC. Geriatrics 2007;7:18.

[25] ²⁵
Longsdon RG, McCurry SM, Teri L. A community-based approach for teaching family caregivers to use behavioral strategies to reduce affective disturbances in persons with dementia. Gerontologist 2005;6:2:146-153.

[26] ²⁶
Perry RJ, Hodges JR. Attencion and executive deficits in Alzheimer's disease- a critical review. Brain 1999;122:3383-3404.

[27] ²⁷
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV) 4th ed. Washington,DC. American Psychiatric Association 1994.

[28] ²⁸
Teri L, McCurry SM, Logsdon R, Gibbons LE. Consultants to help family members improve dementia care: A randomized controlled trial. Gerontologist 2005;45:6:802-811.

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