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Clinical Governance and Practice Development

Why Change Is Needed

Dementia is a critical disease which involves several diseases that can affect cognitive behavioral, memory, and impairs everyday work. The population living with dementia in Australia is about 400,000. The prevalence of dementia is going to be increased by 115.4 million people worldwide (Livingston et al.,2020).

The dementia is typically observed from mild to moderate among the geriatric population. The chances of having dementia in women are more compared to men. Depression and anxiety are the two most common symptom associated with dementia. The rising number of dementia cases will create a burden on the caregivers to choose the intervention. Therefore to choose the best cognitive behavior therapy is a problem statement for the caregivers to treat dementia and to improve the mood and patient wellbeing as well. Previously, the pharmacological therapies have increased the associated risk. Depression and anxiety symptoms got worse, increasing poly pharmacy risk. Counseling therapies did not show much effective results when given with pharmacological therapy majorly in the old aged population. Counseling therapy is a temporary intervention for patients associated with dementia. Cognitive behavioral therapy (CBT) showed effective results when given for a long duration and enhanced the patient output. The study will focus on describing the effective role of cognitive behavioral therapy in patient with dementia. (Livingston et al.,2020).

The cognitive behavior therapy will include several interventions including social, emotional, and spiritual dimensions. The therapy is more effective on young patients compared to older population. Lack of education is a major factor increasing the risk for dementia in the general population. However, the age related dementia has been minimized in most of the nations with increasing education and life style changes. Cognitive behavior therapy will focus on the risk factors forcing the illness like smoking, drug abuse, alcohol, and others (Kraus et al.,2015). Healthcare nurses will participate for effective care implication of the clinical interventions throughout the treatment process. Education should be made compulsory to minimize the associate risk for dementia. Non-pharmaceutical approaches for managing dementia are considered the best intervention compared to psychological therapies like counseling. However, studies are not clear that depict the effective role of cognitive therapies for improving mood and wellbeing in dementia patients. Patients with early symptoms like anxiety and depression will manifest the disease in the later phase of their life. Old age is a expected factor associated with dementia. People above 50 years of age will develop the disease likely. The study will comparative analyze the impact of cognitive behavior therapy and other therapy including counseling for knowing improving the mood and behavior in dementia patients. The study is a part of non-drug cognitive therapies for mild to moderate dementia treatment. 

Research question

Does cognitive behavior therapy affect the mood of dementia patients compared to other therapies such as counseling?

Methods

Inclusion Criteria for study

Population

Dementia patient

Interventions

Cognitive behavior therapy

Comparisons

Other strategies like counseling

Outcomes

Effect on mood

Types of studies included

Meta-analysis studies and RCT

Search strategy

The study was carried out on Jan 17, 2020 with the sequences mentioned below

  1. Dementia or Psychosis
  2. Cognitive behavior therapy or psychological support or clinical interventions
  3. Counseling or guidance
  4. Mood easing strategy or mood improving strategy

Results

Three RCTs two meta-static analyses and one single-arm feasibility study were included in the research study. No economic evaluations were found

Citations

Design of study

Number of participants(the setting)

Evidence level

Key finding in the research papers

Phoebe (2018)

Behavioral Therapy for Older Adults Living in Residential Care

RCT

N=57

comparative studies on CBT alone and psychotherapy

Level -I

CBT alone showed 95% recovery

Psychotherapy(counseling) -5%

Carrion(2018)

Conducted CBT for dementia

Meta-analysis

N=47

(cognitive=10

mental/counseling=25

mixed=12)

Results were compared after 6 months

Level-I

Cognitive= 48%

Mental/counseling=6%

Mixed=46%

Abraha.(2017)

Non-pharmacological interventions for mood improvement

RCT

N=397

sensory stimulation interventions

cognitive/emotion-oriented interventions

Other therapies

and results were arranged after 2-3 weeks

Level-II

Among all therapies, cognitive behavior therapy showed about around 95% impact for enhancing mood

Kok-wai. (2018)

CBT effective in treating depression and anxiety in dementia

RCT

N=11

Multimodal based intervention,

Faith based intervention,

Others

Results were calculated after 6 months

Level- I

Mini-Mental State Examination (MMSE) score range 11-15, where 11 was lowest

Clinical Dementia Rating (CDR) scores range 2-3

Paul. (2016). Behavioral activation to enhance behavior and mood

single-arm feasibility study

N=50

Comparing mood improvement and less depression in CBT Vs Other interventions

Results were obtained after 60min

Level-II

Geriatric Depression Scale-12

No significant results were found for Mini-Mental State Examination

McDermott. (2018). Mental involvement for

dementia

Meta-analysis

N=52

Interventions for improving mood and wellbeing

Physical exercise(PE)

Mental counseling(MC)

Level-I

0-4 is low range,

 5-8 as medium range, and 9-11 as high

Dementia scores for

PE-10

MC-8

The evidence

The study includes various research journals taken from different online journal including, BMC, PubMed. PMC-NCBI. The mentioned six journals were based on meta-analysis review and randomized clinical trials where the co-relation between cognitive behavior therapy and mood improvement and wellbeing is evident. The total 614 patients suffering from mild to moderate dementia participated in the study. The papers were ranging from 2016-2018

Settings: Two studies were conducted in South Australia, North Terrace, Adelaide, Australia (Phoebe, Carrion,2018). One single-arm feasibility study was conducted in South Arab, Iran (Abraha.(2017). One meta-analysis study was carry out in USA, (McDermott,2018)

Participants: In the current total of 50 patients were included in study including both male and female. Age should be ranged more than 50 years were included in the study. All the participants were suffering from dementia or memory loss (McDermott,2018). Some of the participants in the study were collected from patients living in residential areas only (Phoebe 2018). Others participants in the study were specifically associated with anxiety and depression due to dementia (Kok-wai, 2018). Other participants showed the effect of therapies to improve mood and wellbeing (Paul, 2016). The number of patients will be selected randomly for the study including those who were actually receiving CBT from past including those who recently received (McDermott,2018). The study lacked the more strategic results as the patients fail to continue their participation in the study (Abraha,2017). All the details used in the sample collection plan are gathered from secondary research using reviewed and published journals and articles. By gathering the secondary research in our study will enhance the credibility of the study. Written consent was taken from participants before involving them in the study (McDermott,2018 and Phoebe 2018).

Intervention and comparison: The studies used in this research were evaluating the comparative results of cognitive behavioral therapy and counseling (mental therapy). The cognitive therapy was effective parameter used to treat moderate dementia. The intervention was compared with the improved mood and wellbeing in the patients. In this way two groups were created including the test (who showed effective response to therapy) and the experimental group (who showed moderate respond). Written consent from patients and a complete step wise purpose of the study was explained to every patient. Most of the studies were conducted for a maximum duration of 6months.

The focus outcomes has been mentioned in the following headings

Mood improvement in patients with mild to moderate dementia

Cognitive behavior therapy alone improved the mood and wellbeing in patients by 95% as compared with psychotherapy (Phoebe ,2018). Other study showed the Mini-Mental State Examination (MMSE) score range 11-15 (Kok-wai,2018). One study showed Geriatric Depression Scale-12, referring to good behavior and wellbeing. One of the studies was carried for duration of 2-3 weeks (Abraha,2018). Two studies were carries out for maximum duration of 6 months (Carrion and Kok-wai,2018).

Effective therapy

 One of the study showed that among all the cognitive therapies used to manage dementia, music therapy showed maximum effect on the depression and improved the mood and wellbeing. The participants were asked for their music preference to initiate the therapy for effective results. (Paul,2016)

Healthcare nurses in improved therapy

 Two of the studies showed the role of effective role of healthcare nurses. They followed the best care strategies for improved care and patient output. Nurses follow clinical governance to sustain the effectiveness of the study. Education and evident based knowledge played an essential role for improving the cognitive therapies for patient wellbeing (Carrion and Kok-wai,2018). Skill development training and seminars from external expert will guide the nurses to upgrade their knowledge. Clinical leadership knowledge was also helpful to improve therauptic process.

Research gaps

Several gaps exist in the current study and can be further extended in order to achieve a standard protocol for the effective study. Certain gaps were observed throughout the study. The less use of standard tools which will provide validated quantitative results to the current study .This will decreases the future validity of the current research.

Quantitative tools

  • More calculative approach can be considered for future studies to quantify the role of music therapy in treating dementia

Multiple cognitive factors

  • The studies have used multiple cognitive factors including, physical exercise, emotional oriented therapy which makes the study complex to interpret

References for The Effect of Cognitive Therapy on Mood

Abraha, I., Rimland, J. M., Trotta, F. M., Dell’Aquila, G., Cruz-Jentoft, A., Petrovic, M., … Cherubini, A. (2017). Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open, 7(3),1-27

Carrion, C., Folkvord, F., Anastasiadou, D., & Aymerich, M. (2018). Cognitive Therapy for Dementia Patients: A Systematic Review. Dementia and Geriatric Cognitive Disorders, 46, 1–26

Kok-wai, T., Subramaniam, P., & Oei, T. P. (2018). Cognitive behavioural therapy can be effective in treating anxiety and depression in persons with dementia: A systematic review. Psychogeriatrics. 43(4), 1-10.

Kraus, C. A., Seignourel, P., Balasubramanyam, V., SNOW, A. L., WILSON, N. L., KUNIK, M. E., … STANLEY, M. A. (2015). Cognitive-Behavioral Treatment for Anxiety in Patients With Dementia: Two Case Studies. Journal of Psychiatric Practice, 14(3), 186–192.

Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., … Mukadam, N. (2020). Dementia prevention, intervention, and care: Report of the Lancet Commission. The Lancet.45(5),1-7.

McDermott, O., Charlesworth, G., Hogervorst, E., Stoner, C., Moniz-Cook, E., Spector, A., … Orrell, M. (2018). Psychosocial interventions for people with dementia: a synthesis of systematic reviews. Aging& Mental Health, 1–11.

Paul, F., Woodford, J., Llewellyn, D., Anderson, M., Venkatasubramanian, S., Ukoumunne, O. C., … Dickens, C. (2016). Behavioural activation written self-help to improve mood, wellbeing and quality of life in people with dementia supported by informal carers (PROMOTE): A study protocol for a single-arm feasibility study. Pilot and Feasibility Studies, 2(1),1-10

Phoebe, J., Procter, N., Harrison, J., Skelton, K., Hampel, S., Draper, R., & Deuter, K. (2014). Cognitive behavioural therapy for older adults with depression: a review. Journal of Mental Health, 24(3), 168–171.

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