Multidomain interventions have been shown to be effective in improving cognition, reducing symptoms of neuropsychiatric disorders, and delaying functional decline and disability in older
Trang 1NGUYEN XUAN THANH
RESULTS OF A MULTIDOMAIN
INTERVENTION PROGRAM FOR OLDER
PEOPLE WITH DEMENTIA
Specialism : Gerontology Code : 9720107
ABSTRACT OF THESIS
HA NOI - 2024
Trang 2HANOI MEDICAL UNIVERSITY
Supervisors:
1 Supervisor 1 Assoc Prof Ph.D Nguyen Trung Anh
2 Supervisor 2 Ph.D Tran Viet Luc
Trang 3BACKGROUND
1 Background
Dementia is a syndrome characterized by chronic, progressive cognitive decline interfering with daily function, leading to disability and dependency among older people
Dementia is a complex, multifactorial disorder multidomain intervention targeting several risk factors and disease mechanisms may be more effective than single interventions A multidomain intervention was defined as an intervention that intervenes in at least two different domains The Finnish Geriatric Intervention Study (FINGER) is the first trial in the world to demonstrate that multidomain lifestyle interventions, combining physical, cognitive, nutritional, social, and management of metabolic and vascular risk factors can prevent cognitive decline Based on the successful results of the FINGER study, the multidomain intervention model has been applied in various countries worldwide to assess its feasibility across different economic, cultural, and regional contexts Multidomain interventions have been shown to be effective in improving cognition, reducing symptoms of neuropsychiatric disorders, and delaying functional decline and disability in older people with dementia in nursing homes and community
In Vietnam, the prevalence of cognitive decline in the older adults is high and tends to increase rapidly, which poses significant challenges to healthcare and social welfare systems The demand for nursing homes is increasing Many studies have been conducted to assess the current status of dementia in Vietnam, however most have been conducted in hospitals and communities
The prevalence of dementia in nursing homes is higher than in the community, ranging from 53% to 87.1% Residents with dementia often have worse cognitive function than those in hospitals and experience greater difficulty with daily activities compared to those living at home Providing care for older adults with dementia in nursing homes is challenging due to a lack of guidelines and evidence-based treatment Currently, no studies in Vietnam assess the status of dementia or the results of multidomain interventions in older adults living in nursing homes Therefore, we conducted this research with 2 objectives:
Trang 4Objective 1: to describe the the current status of dementia among older people in nursing homes in Hanoi
Objective 2: to investigate the results of a multidomain intervention program for older people with dementia in nursing homes in Hanoi
2 New contributions of the thesis
The current results have shown a high percentage of dementia among older adults in nursing homes in Hanoi Our research findings indicated the presence of geriatric syndromes were highly prevalent among older adults with dementia Geriatric assessments can be applied to older people with dementia in nursing homes and the assistance of the caregiver plays an important role in the geriatric assessment process Geriatric assessment should be identified early to build effective strategies for identifying prevention and intervention strategies
This is the first study to evaluate the feasibility and effectiveness of a multidomain intervention program for older people with dementia in nursing homes in Vietnam The results from the study will inform clinicians and the public of the possibility of comprehensive treatment beyond simple drug treatments for dementia The effectiveness of the intervention has been demonstrated on improving global cognition executive function, language, and functional ability The research results provided information on the effectiveness of multidomain interventions in cultural, social and economic conditions in nursing homes in Hanoi, which will inform policy development on dementia in nursing homes in Vietnam
3 Thesis layout
The thesis has 133 pages, including:
Chapter 1 Literature Review 36 pages
Chapter 2 Subjects and methods 26 pages
Chapter 3 Results 35 pages
Chapter 4 Discussion 31 pages
Recommendations 1 page
The thesis has 36 tables, 9 figures, 2 charts and 4 appendices, 185 references (15 Vietnamese documents, 170 English documents)
Trang 5CHAPTER 1 OVERVIEW
1.1 Epidemiology of dementia
According to the World Health Organization WHO: Currently more than
55 million people have dementia worldwide, over 60% of whom live in low-and middle-income countries
The number of people with dementia in Asia (2021) was 22.9 million, which was more than twice the numbers in Europe (10.5 million) or the Americas (9.4 million)
The number of people living with dementia in Southeast
Asia in 2015 was estimated at 5.51 million, with projections of 6.66 million
in 2020 and 9.6 million in 2030
Currently, in Vietnam, there is no study assessing the prevalence of dementia nationwide The prevalence of cognitive impairment is relatively high, ranges from 14.4–46.4%, depending on the region, sample size and assessment tool
1.2 Definition, causes of dementia
1.2.1 Definition
Dementia refers to a clinical syndrome characterized by chronic and progressive cognitive decline beyond in normal aging that interferes with the ability to function independently
1.2.2 Causes of dementia
Common causes of dementia include: Alzheimer's disease, vascular dementia, mixed dementia, alcoholism, dementia in Parkinson's disease, dementia with Lewy bodies, drug or substance intoxication
1.3 Diagnosis of dementia
1.3.1 Diagnosis
Diagnosis of dementia is a clinical diagnosis, which includes: medical history (ask the patient and their caregiver) and cognitive - neurological examinations
The diagnosis criteria for dementia in research and clinical practice is the DSM V criteria
Trang 61.4 Assessment tools for dementia status
1.4.1 Global cognitive: Mini Mental State Examination (MMSE),
Alzheimer’s Disease Assessment Scale–Cognitive Subscale Cog), Clinical Dementia Rating scale (CDR)
Executive function: executive function tests
1.4.3 Neuropsychiatric behavior assessment:
Neuropsychiatric Inventory (NPI)
1.4.4 Daily activity assessment: Basic Activities of Daily Living (ADL)
and Instrumental Activities of Daily Living (IADL)
1.4.5 Physical function tests: hand grip strength measurement,
30-second chair stand test, and Timed up-and-go test
1.4.6 Geriatric syndrome assessment: polypharmacy, malnutrition,
frailty syndrome, sarcopenia, dysphagia, urinary incontinence, falls, and sleep disorders
1.4.7 Quality of life assessment: Quality of Life in Alzheimer’s Disease
Drugs for the treatment of behavioral and psychological symptoms
of dementia (BPSD): selective serotonin reuptake inhibitors and atypical antipsychotics
Disease-modifying treatment: currently, Aducanumab is available,
a disease-modifying drug targeting amyloid β
Trang 7Social interventions: often incorporated within multidomain intervention models
Monitoring and intensive management of metabolic and vascular risk factors: controlling hypertension, hypercholesterolemia, and diabetes
Other non-pharmacological interventions: massage therapy, sensory stimulation, reminiscence therapy, music therapy, aromatherapy, virtual reality interventions, electroacupuncture, and non-invasive brain stimulation using transcranial magnetic stimulation
multi-1.6 Multidomain intervention
1.6.1 Definition
Multidomain interventions involve a comprehensive approach that integrates at least two different domains, combining both pharmacological and non-pharmacological strategies
1.6.2 Methods of multidomain interventions
• Frequency: 3 to 6 times per week
• Total duration: between 6 and 48 weeks
• Session length: 30 to 180 minutes per session
• Types of interventions: can be delivered through various
methods (in-person, phone, or online) and involve a combination of exercise, reminiscence, art therapy, gardening, music therapy, cognitive training, daily living activities, neurorehabilitation, recreational therapy, laughter therapy, crafts, and more
• Target population: mild cognitive impairment and dementia
• Intervention team: a coordinated multidisciplinary team
including doctors, nurses, rehabilitation specialists
1.6.3 Results of multifactorial interventions
Multidomain intervention yield positive results in global cognitive function, executive function, attention, memory, spatial awareness, physical health, quality of life, and reduction in behavioral and psychological symptoms of dementia
Trang 8CHAPTER 2 MATERIALS AND METHODS
mild-2.2 Time and location
- Time: From September 2020 to December 2023
- Location: Private nursing homes in Hanoi (Dien Hong facilities 1,2,3,4, Nhan Ai, Orihome)
2.3 Study methods
2.3.1 Study design
Objective 1: A cross-sectional study
Objective 2: A two-armed 6-month, randomized controlled study 2.3.2 Sample size estimates and randomisation
Objective 1: The sample size was calculated using a formula to
determine the proportion for a population, with a minimum required sample size of 381 older adults from the nursing homes In final, the sample size for objective 1 was 382 participants
Objective 2: The sample size was calculated using a paired sample
formula to test the difference between two means Allowing for a 15% dropout rate and 5% mortality, the minimum required sample size was
29 per study arm The final sample size was 30 per study arm
2.4 Sampling methods
2.4.1 Sampling method for objective 1
A comprehensive list of residents aged 60 years and older in nursing homes was compiled Eligible participants were screened using the MMSE Participants who scored below 24 on the MMSE underwent a clinical evaluation to diagnose dementia Participants diagnosed with
Trang 9dementia who gave their consent were included in the assessment for objective 1
2.4.2 Sampling Method for objective 2
Participants for objective 2 were selected from residents with dementia who met the inclusion and exclusion criteria and completed all assessments in objective 1 A randomized stratified matching method was employed, stratifying by age (60–69, 70–79, 80 and over) and disease severity (mild or moderate) Participants will be randomized in a 1:1 ratio to either intervention or control
2.5 Pre-intervention Training
The expert team held meetings to finalize the intervention methods, which integrated cognitive, physical, and social interventions, along with managing vascular and metabolic risk factors The cognitive and physical intervention were cognitive stimulation activities and resistance exercises
The study coordinator created the schedule for the entire intervention program and organized monthly team meetings
The intervention team consisted of one technician from the National Geriatrics Hospital, two internal medicine doctors, a rehabilitation specialist, and three technicians in nursing homes
2.6 Research Procedure
Objective 1: All participants were evaluated using a standardized
medical record form, which included medical interviews, physical and neurological examination
Objective 2: Participants were randomized into two equal groups, to
receive either a multidomain intervention (intervention group) or regular health advice (control group)
Both the intervention and control groups were assessed at baseline, after 3 months, and after 6 months Data were obtained through four approaches: (1) in-person interviews with study participants; (2) examination of the participants, including physical tests such as grip strength measurements, a 30 s chair stand test (30 s CST), the Timed Up &
Trang 10Go (TUG) test; (3) interviews with the nursing home care staff; and (4) review of nursing home records Study participants and nursing home care staff were interviewed separately using a structured questionnaire
2.7 Study Variables
* General information: demographic characteristics, anthropometric index
and medical history, behavioral characteristics
* Current status of dementia
Evaluations at study initiation: the prevalence of dementia in nursing homes, characteristics of dementia syndrome, global cognition, attention-concentration, memory, language, orientation, executive function, daily activities, physical function, behavioral and psychological symptoms, geriatric syndromes, quality of life
* Assessment of the results of multidomain intervention
The results of multidomain intervention were assessed based on the changes at 6 months compared to the start of the study in the following areas: feasibility of the study (recruitment, adherence and retention), global cognition, attention-concentration, memory, language, orientation, executive function, functional ability, physical function, behavioral and psychological symptoms, geriatric syndromes, quality of life, mortality
2.9 Data Analysis
Data were entered using Redcap software and performed using STATA version 17 A p -value of 0.05 was considered significant
Trang 11Objective 1:
Categorical variables were presented as mean ± standard deviation or medians and confidence intervals Fisher's exact test was used to compare categorical variables between the two groups, while Mann-Whitney test was used to compare continuous variables between the two groups
The analysis was primarily based on 107 participants who completed all assessments for objective 1 of the study For the quality of life analysis, data from 140 participants who completed the QOL-AD questionnaire were used Potential factors associated with the QOL-AD score in the univariate analysis at a threshold of p-value less than 0.20 were entered in our multi-variable adjusted logistic regression models
Objective 2:
Data were analyzed on an intention-to-treat (ITT) basis, where in participants were analyzed according to their treatment assignment by randomization, regardless of their compliance
To investigate the treatment effects on continuous outcomes, we
utilized Linear Mixed-effects Model (LMM) with random slopes
For binary outcomes, the Generalized Estimating Equation models (GEE) were applied as our causal effects of interest are the population-average effects
Handling missing values
We applied direct likelihood method, which is valid under LMM, to address missing values for continuous outcome models
For binary outcomes models, the Multiple Imputation by Chained Equations (MICE) method was employed
Trang 12CHAPTER 3 RESULTS
A total of 382 older adults in nursing homes were screened for eligibility, of whom 164 were diagnosed with dementia Of 164 participants with dementia, 53 did not complete the questionnaire, 2 returned home, and 2 decided not to participate A total of 107 participants completed all assessments in objective 1 There were 100 participants met the criteria for objective 2 and were randomly assigned to groups: 30 in the intervention group and 30 in the control group (recruitment rate was 60%) After 6 months
of intervention, 4 participants in the intervention group and 3 participants in the control group dropped out
Figure 3.1 Prevalence of dementia in private nursing homes in Hanoi (n=382)
Comment: There are 164 older people with dementia at the nursing homes,
n=40 (37.4%)
Moderate n=60 (56.1%)
Several n=7 (6.5%)
n (%)
No 40 (100) 60 (100) 7 (100) 107 (100)
- Yes 0 (0) 0 (0) 0 (0) 0 (0) Rivastigmine,
n (%)
No 40 (100) 60 (100) 7 (100) 107 (100)
- Yes 0 (0) 0 (0) 0 (0) 0 (0) Donepezil,
n (%)
No 40 (100) 60 (100) 7 (100) 107 (100)
- Yes 0 (0) 0 (0) 0 (0) 0 (0) Galantamine,
n (%)
No 40 (100) 59 (98.3) 7 (100) 106 (99.1)
0.67 Yes 0 (0.0) 1 (1.7) 0 (0.0) 1 (0.9)
42,93%
57,07%
Yes No
Trang 13Comments: There was 16.8% of the participants had been diagnosed
with dementia before participating in the study (46.2%), however, only 1 participant had used Galantamine
Table 3.2 Characteristics of global cognitive function of participants (n=107)
Characteristics
Dementia
Total p Mild
n=40 (37.4%)
Moderate n=60 (56.1%)
Several n=7 (6.5%)
42.52 (13.8)
27.69 (9.9) <0.001 Median
(CI)
21.67 (17.33;
25)
27.67 (24.08;
35.5)
38.67 (29.33;
58.67)
25.33 (20.33;
16.75 (3.96) <0.001 Median
(CI)
19 (18; 21.75)
15 (13; 17)
13 (10; 16)
17 (14; 19) <0.001
Comments: The average ADAS and MMSE scores of the participants
were 27.69 (9.9) and 16.75 (3.96) respectively
Table 3.3 Some geriatric syndromes of the participants (n=107)
Characteristics
Dementia
Total p Mild
n=40 (37.4%)
Moderate n=60 (56.1%)
Several n=7 (6.5%)
Number of
falls
Mean (SD) 1.33 (1.05) 1.54 (2.41) 0 (0) 1.43 (1.97) 0.74 Median (CI) 1(1; 2) 1 (0; 2) 0 (0; 0) 1 (0; 2) 0.41 Sleep quality,
n (%)
Good 12 (30) 15 (25) 3(42.9) 30 (28)
0.57 Poor 28 (70) 45 (75) 4(57.1) 77 (72) Nutrition,
n (%)
Risk of malnutrition 24 (60) 24 (40) 1(14.3) 49 (45.8) 0.03 Malnutrition 16 (40) 36 (60) 6 (85.7) 58 (54.2) Frailty No 3 (7.5) 3 (5) 1 (14.3) 7 (6.5)
0.91 Pre-frailty 24 (60) 36 (60) 4 (57.1) 64 (59.8) Yes 13(32.5) 21 (35) 2 (28.6) 36 (33.6)
Comments: Nearly one-third of the participants (27.1%) had a history
of falls in the past 6 months with an average number of falls of 1.43 (1.97) The prevalence of poor sleep was 72% The prevalence of