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      Toward a theory-based specification of non-pharmacological treatments in aging and dementia: Focused reviews and methodological recommendations

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      1 , 2 , 3 , 1 , 2 , 1 , 2 , 4 , 5 , 6 , 7 , 8 , 9 , 9 , 10 , 11 , 12 , 13 , 14 , 10 , 15 , 16 , 17 , 15 , 18 , 19 , 13 , 10 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 27 , 15 , 28
      Alzheimer's & dementia : the journal of the Alzheimer's Association
      cognitive rehabilitation, cognitive stimulation therapy, cognitive training, cognitive-behavioral therapy for insomnia, communication treatments, framework, meditation, mild cognitive impairment, multisensory treatments, music-based treatments, neuromodulation, neuropsychiatric, non-pharmacological, nutritional interventions, occupational therapy, physical exercise training, reminiscence therapy, subjective cognitive decline

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          Abstract

          Introduction:

          Non-pharmacological treatments (NPTs) have the potential to improve meaningful outcomes for older people at risk of, or living with dementia, but research often lacks methodological rigor and continues to produce mixed results.

          Methods:

          In the current position paper, experts in NPT research have specified treatment targets, aims, and ingredients using an umbrella framework, the Rehabilitation Treatment Specification System.

          Results:

          Experts provided a snapshot and an authoritative summary of the evidence for different NPTs based on the best synthesis efforts, identified main gaps in knowledge and relevant barriers, and provided directions for future research. Experts in trial methodology provide best practice principles and recommendations for those working in this area, underscoring the importance of prespecified protocols.

          Discussion:

          We conclude that the evidence strongly supports various NPTs in relation to their primary targets, and discuss opportunities and challenges associated with a unifying theoretical framework to guide future efforts in this area.

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          Most cited references112

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          NIA-AA Research Framework: Toward a biological definition of Alzheimer’s disease

          In 2011, the National Institute on Aging and Alzheimer’s Association created separate diagnostic recommendations for the preclinical, mild cognitive impairment, and dementia stages of Alzheimer’s disease. Scientific progress in the interim led to an initiative by the National Institute on Aging and Alzheimer’s Association to update and unify the 2011 guidelines. This unifying update is labeled a “research framework” because its intended use is for observational and interventional research, not routine clinical care. In the National Institute on Aging and Alzheimer’s Association Research Framework, Alzheimer’s disease (AD) is defined by its underlying pathologic processes that can be documented by postmortem examination or in vivo by biomarkers. The diagnosis is not based on the clinical consequences of the disease (i.e., symptoms/signs) in this research framework, which shifts the definition of AD in living people from a syndromal to a biological construct. The research framework focuses on the diagnosis of AD with biomarkers in living persons. Biomarkers are grouped into those of β amyloid deposition, pathologic tau, and neurodegeneration [AT(N)]. This ATN classification system groups different biomarkers (imaging and biofluids) by the pathologic process each measures. The AT(N) system is flexible in that new biomarkers can be added to the three existing AT(N) groups, and new biomarker groups beyond AT(N) can be added when they become available. We focus on AD as a continuum, and cognitive staging may be accomplished using continuous measures. However, we also outline two different categorical cognitive schemes for staging the severity of cognitive impairment: a scheme using three traditional syndromal categories and a six-stage numeric scheme. It is important to stress that this framework seeks to create a common language with which investigators can generate and test hypotheses about the interactions among different pathologic processes (denoted by biomarkers) and cognitive symptoms. We appreciate the concern that this biomarker-based research framework has the potential to be misused. Therefore, we emphasize, first, it is premature and inappropriate to use this research framework in general medical practice. Second, this research framework should not be used to restrict alternative approaches to hypothesis testing that do not use biomarkers. There will be situations where biomarkers are not available or requiring them would be counterproductive to the specific research goals (discussed in more detail later in the document). Thus, biomarker-based research should not be considered a template for all research into age-related cognitive impairment and dementia; rather, it should be applied when it is fit for the purpose of the specific research goals of a study. Importantly, this framework should be examined in diverse populations. Although it is possible that β-amyloid plaques and neurofibrillary tau deposits are not causal in AD pathogenesis, it is these abnormal protein deposits that define AD as a unique neurodegenerative disease among different disorders that can lead to dementia. We envision that defining AD as a biological construct will enable a more accurate characterization and understanding of the sequence of events that lead to cognitive impairment that is associated with AD, as well as the multifactorial etiology of dementia. This approach also will enable a more precise approach to interventional trials where specific pathways can be targeted in the disease process and in the appropriate people.
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            The behaviour change wheel: A new method for characterising and designing behaviour change interventions

            Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.
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              Dementia prevention, intervention, and care

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                Author and article information

                Contributors
                On behalf of : ISTAART Non-pharmacological Interventions Professional Interest Area
                Journal
                101231978
                33173
                Alzheimers Dement
                Alzheimers Dement
                Alzheimer's & dementia : the journal of the Alzheimer's Association
                1552-5260
                1552-5279
                24 February 2021
                20 November 2020
                February 2021
                18 March 2021
                : 17
                : 2
                : 255-270
                Affiliations
                [1 ]Alzheimer Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, the Netherlands
                [2 ]Department of Clinical, Neuro- and Developmental Psychology, VU University, Amsterdam, the Netherlands
                [3 ]Department of Neurology, Xuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric Disorders, Beijing, China
                [4 ]School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
                [5 ]Centre for Healthy Brain Ageing and Dementia Centre for Research Collaboration, School of Psychiatry, UNSW, Sydney, Australia
                [6 ]Centre for Research in Ageing and Cognitive Health, College of Medicine and Health, University of Exeter, Exeter, UK
                [7 ]Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
                [8 ]Medical School, University of Western Australia, Perth, Western Australia, Australia
                [9 ]Normandie Univ, UNICAEN, INSERM, U1237, PhIND “Physiopathology and Imaging of Neurological Disorders,”Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
                [10 ]Section on Nutrition and Nutritional Epidemiology, Department of Internal Medicine, Rush University, Chicago, Illinois, USA
                [11 ]Department of Neurology, Oregon Health and Science University, Portland, Oregon, USA
                [12 ]Department of Neurology, University of Michigan,Ann Arbor, Michigan, USA
                [13 ]Department of Psychiatry, Amsterdam University Medical Center, VUmc, Amsterdam, the Netherlands
                [14 ]Department of Psychiatry, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
                [15 ]Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
                [16 ]Department of Rehabilitation, Aged and Extended Care, College of Medicine and Public Health Flinders University, Adelaide, Australia
                [17 ]Lyon Neuroscience Research Center INSERM U1028, CNRS UMR5292, Lyon University, Lyon, France
                [18 ]NorthWestern Mental Health, Melbourne Health, Melbourne, Australia
                [19 ]Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA
                [20 ]Wisconsin Alzheimer’s Institute, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
                [21 ]Department of Psychology, University of New South Wales, Randwick, Sydney, Australia
                [22 ]Neuroscience Research Australia, Sydney, Australia
                [23 ]The University of East Anglia, Norwich, UK
                [24 ]Department of Clinical, Educational & Health Psychology, University College London, London, UK
                [25 ]Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
                [26 ]Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
                [27 ]Faculty of Fine Arts and Music, University of Melbourne, Melbourne, Victoria, Australia
                [28 ]Centre for Research on Ageing, Health, and Wellbeing, Research School of Population Health, The Australian National University, Canberra, Australia
                Author notes
                Correspondence: Sietske A.M. Sikkes, Amsterdam University Medical Centers, Alex Bahar-Fuchs, University of Melbourne, Alzheimer Center Amsterdam, PO Box 7057, 1007 MB, PK-1 Z052, Amsterdam, the Netherlands. s.sikkes@ 123456amsterdamumc.nl ; alex.bahar@ 123456unimelb.edu.au
                Article
                NIHMS1673781
                10.1002/alz.12188
                7970750
                33215876
                7cd1f096-e177-4a42-8075-180c2041ecc9

                This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

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                cognitive rehabilitation,cognitive stimulation therapy,cognitive training,cognitive-behavioral therapy for insomnia,communication treatments,framework,meditation,mild cognitive impairment,multisensory treatments,music-based treatments,neuromodulation,neuropsychiatric,non-pharmacological,nutritional interventions,occupational therapy,physical exercise training,reminiscence therapy,subjective cognitive decline

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