Enhanced Cognitive Behavioral Therapy for Patients with Anorexia Nervosa

Delaney C. MuldoonUniversity of Maryland, School of Nursing

Background

• AN is a a disorder “characterized by weight loss, difficulty maintaining an appropriate body weight, and distorted body image” (National Eating Disorders Association, 2018 )

• CBT-E is individualized therapy designed to help the patient understand their eating disorder and teach long-term strategies to reduce relapse rates (Grave & Murphy, 2020)

• CBT-E can be implemented on an outpatient basis, is broken into 4 phases and carried out over the course of 20 weeks (Grave & Murphy, 2020)

Significance

• AN is the leading cause of death among individuals with eating disorders (National Eating Disorders Association, 2018)

• Pharmacotherapy treatment for AN has proven to be ineffective as many patients are in denial of the eating disorder and refuse treatment (Flament et al., 2012).

• Traditional psychotherapy alone is unable to treat the complexity of AN (Natenshon, 2017).

• 80% of individuals with an eating disorder who seek out and complete treatment will recover or see significant improvements (Eating Recovery Center)

Methods

PICOT QuestionP: adult patients with anorexia nervosa in the outpatient settingI: CBT-E treatment C: treatment as usualO: improvement in EDE-Q and BMI scores

Search StrategyThe Embase database was used to conduct a search for articles. The search utilized the terms “eating disorder treatment” AND “CBT-E.” The search was further filtered to include include only randomized control trials, case control studies, case studies, feasibility studies, major clinical studies, prospective studies, and multicenter studies. Articles were excluded if they occurred in inpatient settings, addressed other types of eating disorders or focused on children with eating disorders. The remaining five articles were used as evidence.

Key Terms AN: anorexia nervosa CBT-E: enhanced cognitive behavioral therapyEDE-Q: Eating Disorder Exam QuestionnaireBMI: body mass index

Evidence Synthesis • All studies, except for Zipfel et al., found statistically

significant differences in those individuals who received CBT-E

• Two studies provided low quality evidence they were quasi-experimental design and lacked a control group, did not meet sufficient statistical power, and had high levels of attrition (Fairburn et al., 2013; Wade et al., 2017).

• Three studies were randomized control trials and provided good quality evidence by conducting the research at multicenter settings and reporting adequate power (Zipfel et al., 2013; de Jong et al., 2020; Carter et al., 2011).

Implications for Nursing and Role of the CNL

• A shortage of specialists to deliver CBT-E opens the door to the possibility of nurses receiving additional training to implement this therapy

• Nurses and CNLs are in a position to involve patients in their care, by offering education about CBT-E and other treatment options

• CNLs have the tools to lead future research on this topic to find the strongest evidence to make a practice change and disseminate the findings to colleagues

Summary and Conclusion

• CBT-E to treat adults in with anorexia nervosa has proven to have positive effects such as increase in body mass index, as well as improvement in EDE-Q scores in outpatient settings.

• Additional high-quality studies should be carried out to support the implementation of CBT-E.

• Nurses and CNLs are equipped with the knowledge and skill set to educate and support patients as they choose which treatment to treat their eating disorder.

• Additional evidence should be carried out to determine the effectiveness in CBT-E improve recovery rates for adults with anorexia nervosa.

References

de Jong, M., Spinhoven, P., Korrelboom, K., Deen, M., van der Meer, I., Danner, U., van der Schuur,Schoorl, M., & Hoek, H. (2020). Effectiveness of enhanced cognitive behavior therapy for eatingdisorders: a randomized controlled trial. International Journal of Eating Disorders. 53(5), 717-727. https://doi.org/10.1002/eat.23239

Fairburn, C., Cooper, Z., Doll, H., O’Connor, M., Palmer, R., & Grave, R. (2013). Enhanced cognitive behavior therapy for adults with anorexia nervosa: a uk-italy study. Behavior Research and Therapy. 51(1). https://10.1016/j.brat.2012.09.010

Flament, M., Bissada,H., & Spettigue, W. (2012). Evidence-based pharmacotherapy of eatingdisorders. International Journal of Neuropsychopharmacology. 15(2), 189-207. https://doi.org/10.1017/S1461145711000381

Natenshon, A. (2017, February 1). Eating disorders: a treatment apart. The unique use of the therapist’s self in the treatment of eating disorders. https://www.intechopen.com/books/eating-disorders-a-paradigm-of-the-biopsychosocial-model-of-illness/eating-disorders-a-treatment-apart-the-unique-use-of-the-therapist-s-self-in-the-treatment-of-eating

Wade, S., Byrne, S., & Allen, K. (2017). Enhanced cognitive behavioral therapy for eating disordersadapted for a group setting. International Journal of Eating Disorders. 50(8), 863-872. https://doi-org.proxy-hs.researchport.umd.edu/10.1002/eat.22723

Zipfel, S., Wild, B., Grob,G., Friederich, H., Teufel, M., Schellberg, D., Giel, K., de Zwann, M., Dinkel,A., Herpertz, S., Burgmer, M., Lowe, B., Tagay, S., von Wietersheim, J., Zeeck, A., Schade-Brittinger, Schauenburg, H., & Herzog, W. (2013). Focal psychodynamic therapy, cognitive behavior therapy, ad optimized treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomized controlled trial. The Lancet. 383, 127-137. http://dx.doi.org/10.1016/S0140-6736(13)61746-8

• Among adolescents, suicide is one of the leading causes of deaths in this country, and rates have been increasing since 2007.

• In 2015, 7-11% of adolescents reported 1-year repeated occurrence of suicide attempts, while around 24% reported thoughts of suicide.

• Suicide has worsened around the World since Covid-19 pandemic with 18 adolescents' suicides in 9-month months of lockdown compared to 9 entire 2019 in one of the United States cities.

• In 1993, suicide ranked as the 14th leading cause of death among African American adolescents, but currently it is the 10th leading cause of death with rates nearly twice that of their White Counterparts. Post discharge suicide rate is very high.

• The Zero Suicide (ZS) Model framework and resources is an effective evidence-based intervention tool.

• Also, incorporating an effective family focused discharge program can be a buffer against the harmful effects of negativity interaction on depressed patient’s suicidality, which helps in developing more accurate expectations of therapy role behaviors that the patients are likely to encounter as outpatients which is needed to reduce relapse.

Background

PICOT

Methods

Conclusion

1. Brodsky, B. S., Spruch-Feiner, A., & Stanley, B. (2018). The zero-suicide model: applying evidence-based suicide prevention practices to clinical care. Journal of Front Psychiatry, 9, 33-38. Doi: 10.3389/fpsyt.2018.00033

2. Chung, D., Ryan, C., Hadzi-Pavlovic, D., Singh, S., Stanton, C., & Large, M. (2017). Suicide Rates After Discharge from Psychiatric Facilities. A Systematic Review and Meta-analysis. Doi: 10.1001/jamapsychiatry.2017.1044

3. Curtin, S. & Heron, M. (2019). Death Rates Due to Suicide and Homicide Among Persons Aged 10-24: United States, 2000-2017. Retrieved from http://www.cdc.gov/nchs/products/databriefs/db352.htm

4. Cutin, S. C., Warner, M., Hedehaard, H. (2016). Increase in suicide in the United States, 1999-2014. NCHS Data Brief, 24, 1-8

5. Forte, A., Buscajoni, A., Fiorillo, A., Pompili, M., & Baldessarini, R. (2019). Suicide Risk Following Hospital Discharge: A Review. Doi: 10.1097/HRP.0000000000000222

6. Green, E. (2021). Surge of Student Suicides Pushes Las Vegas Schools to Reopen. Retrieved from https://www.nytimes.com/2021/01/24/us/politics/student-suicides-Nevada-coronavirus.html

7. Hetrick, S. E., Yuen, H. P., Bailey, E., Cox, G. R., Templer, K., Rice, S. M., Bendall, S., & Robinson, J. (2017). Internet-based cognitive behavioral therapy for young people with suicide-related behavior (Reframe-IT): a randomized controlled trial. Evidence Based Mental Health, 20(3), 76-82. https://doi.org/10.1136/eb-2017-102719

8. Holliday-Moore (2019). Alarming Suicide Trends in African American Children: An Urgent Issue. https://blog.samhsa.gov/2019/07/23/alarming-suicide-trends-in-African-American-children-an-urgent-issue

9. Jocelyn, D., Robinson, W., & Jason, L. (2017). Suicidality Protective Factors for African American Adolescents: A Systematic Review of the Research Literature. SOJ Nursing Health Care. 2017; 3(2): Doi: 15226/2471-6529/3/2/00130

10.Joint Commision (2016). Sentinel Event Alert – Detecting and treating suicide ideation in all settings. Retrieved from www.jointcommission.org.

11.Krause, T., Lederer, A., Sauer, M., Schneider, J., Sauer, C., Jabs, B., Elzersdorfer, E., Genz, A., Bauer, M., Richter, S., Rujescu, D., & Lewitzka, U. (2020). Suicide risks after psychiatric discharge: study protocol of a naturalistic, long-term, prospective observational study. Doi: 10.1186/s40814-020-00685-z

12.Nguyen, A. W., Taylor, R. J., Chatters, L. M., Taylor, H. O., Lincoln, K. D., & Mitchell, U. A. (2016). Extended family and friendship support and suicidality among African Americans. Social Psychiatry Epidemiology. https://doi.org/10.1007/s00127-016-1309-1

13.Price, J. & Khubchandani, J. (2019). The Changing Characteristics of African American Adolescents Suicide, 2001 –2017. Journal of Community Health, 44(4), 756- 763. https://doi.org/10.1007/s/10900-019-00678-x

14.State Operations Manual Appendix AA – Psychiatric Hospitals – Interpretive Guidelines and Survey Procedures (Rev. 149, 10-09-15). Retrieved from https://www.cms.gov./Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_aa_psyc_hospitals.pdf

15.Sisler, S., Schapiro, N., Nakaishi, M., & Steinbuchel, P. (2020). Suicide assessment and treatment in pediatric primary care settings. Doi: 10.1111/jcap.12282

16.Stanley, B., Labouliere, C., Brown, G., Green, K., Galfalvy, H., Finnerty, M., Vasan, P., Cummings, A., Wainberg, M., Carruthers, J., & Dixon, L. (2021). Zero suicide implementation-effectiveness trial study protocol in outpatient behavioral health using the A-I-M suicide prevention model. Doi: 10.1016/j.cct.2020. 106224

Bibliography

Database: PsychInfo, PubMedKeywords: Suicide, Prevention, Evidence-based, Psychiatric, African American, AdolescentsInclusion Criteria: African American adolescent participants, Published 2016-2021, adult focused, English language, highest quality research studies, Evidence-based Zero Suicidal treatments and care in psychiatric settingsExclusion Criteria: Abstract and content irrelevant to PICOT, non-clinical study, no sample characteristicsResults: Total of 37 articles identified and screened. Final Five (5) articles including 3 randomized controlled trials (RCT) and 2 meta-analysis Review.

Nursing Implications

Acknowledgement

• A discharge program that is effective can facilitate teaching and provision of needed information that a suicidal depressed African American adolescents needs for follow –up care.

• This process will enable the Clinical Nurse Leader (CNL) to develop a good accurate expectations of therapy role behaviors that are likely to be encountered as outpatients.

• By using basic tasks of core-competencies, the CNL will engage in a continuing conversations with patients regarding suicide assessment, monitoring tools, risks anticipation, as well as intervention strategies.

• The Zero Suicide (ZS) Model elements of clinical care emphasize that systematic protocols should involve ongoing risk screening and assessment, collaborative safety planning, access to evidence-based suicide-specific care, focus on lethal means reduction, consistent engagement efforts, and support during high-risk periods.

• This discharge protocols strives to observe and provide basic level of care for patients such as universal screening and comprehensive risk assessment on a regular basis, and engagement of high-risk patients on a Suicide-safer Care Pathway (SSCP) that provides specialized care and increase contact as was recommended by National Action Alliance for Suicide Prevention 2019.

• An extended systematic review of evidence-based findings in suicide prevention of Zero Suicide Model addresses the fluctuating nature of suicide risk, ongoing risk assessment, population screening combined with chain of care, follow-up, direct intervention, and monitoring as the best practice to prevent suicide among high-risk patients.

• The ZS model is significant framework that will facilitate increased patients’ safety and improve their quality of care because its discharge protocols demonstrate influence on suicide prevention by setting care with regular personal contact after discharge.

• By coordinating a multilevel approach to implement evidence-based practices to prevent suicide, the Zero Suicidal Model can protect against the dangerous effects of adverse interactions on depressed patient’s suicidality.

• This approach will also enable the CNL to develop more accurate expectations of therapy role behaviors that the patients are likely to encounter after discharge, and recognize the potential influence of anger, frustration, and anxiety in the assessment and management process of discharged depressed African American patients.

• Understanding personal beliefs of this group about suicide and their potential influence will be a priority to the CNL and geared treatment towards relief of emotional pain and suffering.

Effectiveness of Zero Suicide Model in reducing adolescent outpatient suicide rateEMMANUEL NWAIWU, MSN-CNLUniversity of Maryland School of Nursing

To evaluate the effectiveness of evidence-based Zero Suicidal (ZS) Framework in reducing outpatient suicidal rate for adolescent African American patients with Major Depressive Disorder (MDD) discharged from inpatient behavioral health unit.

I would like to express my profound gratitude to Dr. Stephanie Streb -DNP for her guidance, mentorship and constructive feedbacks as well as her recommendation throughout this project. Also, I would like to thank Dr. Sherrie Lessans for her suggestions and input during the topic selection process. To my wife, children and family who have been encouraging and supportive throughout this program, thank you.

Role of the CNL• Educator: Provide education and teachings to providers on the benefits of incorporating

family/friends during discharge of African American adolescent to improve safety as outpatient and reduce chances of relapse.

• Clinician: utilize evidenced-based ZS model as an effective family focused discharge that can buffer against the harmful effects of negative interaction on depressed adolescents’ patient’s suicidality.

• Patient Advocacy: Provide recommendations and empowering patients on better ways to advocate for themselves to improve their safety and facilitate effective care outcome after discharge.

• Evidences of this study suggests the benefits of Zero Suicide (ZS) interventions model in reducing suicide rate among African American adolescents.

• ZS model uses a multilevel approach that coordinates patients teaching, consistent engagement and supports during high-risk period.

• ZS interventions are non-pharmacological evidence-based inpatients discharge treatment plan that enhances outpatients’ recovery and minimizes patients’ relapse after discharge.

Mindfulness-Based Stress Reduction to Decrease Incidence of Generalized Anxiety Disorder Symptoms

Grace Parrish, University of Maryland, Baltimore School of Nursing. Clinical Nurse Leader ProgramAcknowledgements: Dr. Kristen Rawlett, Ph. D., FNP-BC, FAANP. Spring 2021

Background

Patients diagnosed with generalized anxiety disorder (GAD) can experience debilitating symptoms that impact the ability of the individual to function daily, including excessive feelings of anxiety, worry, and depression. The substantial persistence of GAD symptoms after current mechanisms of therapy, coupled with the tendency for individuals to not seek psychiatric therapy due to the associated stigma rationalizes the need for a cost-effective solution with less stigma. Mindfulness-based stress reduction (MBSR) trains participants with meditation techniques that promote awareness of their current experiences by regulating thoughts and emotions through self-acceptance. Existing research on mindfulness-based stress reduction (MBSR) has demonstrated reduction in symptoms of anxiety and an improvement to patients’ quality of life (Asmaee Majid et al., 2012).

• Studies supported the efficacy of MBSR in the reduction of GAD symptoms of anxiety, depression, and worry, and increased quality of life from baseline to end of study

• Higher rated studies included an SME attention control group to draw more accurate conclusions

• MBSR skills may empower those with GAD with flexibility in emotional reaction• Equipped with ability to reduce debilitating manifestation of

anxious thought patternsAdditional research studies should include:• Larger sample sizes• Specify adequate power needed

• Attention-control comparison group such as SME • Outcome measures with minimal reliance on self-reporting

Conclusion

MethodsAn evidence search was performed with the databases PubMed and EBSCOhost. Keywords searched included: mindfulness-based stress reduction and generalized anxiety disorder. Years included were 2011-2021. 32 articles were reviewed after elimination of others due to design flaws. Five primary research studies were reviewed which analyzed the impact of MBSR on symptoms of GAD.

PICOT:P: Adult patients diagnosed with Generalized Anxiety DisorderI: mindfulness based therapeutic intervention C: traditional care for GAD O: reduced anxiety symptoms based on GAD-7T: during therapeutic treatment period for GAD

Evidence Summary

Design• Five randomized controlled trials• Participants not blinded

Sample• Convenience sampling• From 29-92 participants• One study only females

Data Collection• Four studies used standardized questionnaires for:• Anxiety, worry, depression, and quality of life

• Surveyed at baseline and after intervention period• One study measured fMRI imaging to measure areas in the brain associated with

emotional regulation• Two studies included state anxiety and stress reactivity measures• In a laboratory simulated stress encounter, Trier Social Stress Test (TSST), measured

by:• One study measured stress hormone impact on the Hypothalamic-Pituitary

Adrenal (HPA) Axis and inflammation markers in bloodstream pre- and post-TSST

• The second, state anxiety questionnaire

Intervention• MBSR standard protocol• Eight weeks of MBSR group-based therapy• Leader MBSR certified• Sessions two hours long, once per week, and one retreat day• Audio recordings assigned for home practice

Control • Two of the studies treatments as usual: pharmacology and individual psychotherapy • Three higher-rated studies included an attention control group: Stress Management

Education (SME)• SME group lecture classes taught health and wellness• Congruent design, eight week period of two-hour, weekly classes with one retreat

day• Active attention SME group to control for non-specific effects of treatment• For example: group support, attention from instructor, expectation of participants

Outcomes• Significant reduction in GAD-associated symptoms, and improvement in quality of life

ratings, from baseline to post-intervention in MBSR group but not in the control group• One study did not show significant reduction in one of the five subjective

questionnaires in the MBSR group compared to the SME• Significant difference in the reduction in both inflammation markers and one of the

HPA Axis hormone indicators in MBSR compared to change in SME• fMRI scans showed significant improvement in functional connectivity between the

amygdala and the prefrontal cortex in MBSR but not SME

Nursing Practice & CNL Implications

MBSR reduces judgement of present moment or patients with GAD• Can promote psychological resilience • Can reduce incidence of maladaptive habits

Implementation benefits• Inexpensive intervention• Less stigma compared to other psychiatric treatment

• Evidence Grade of C on USPSTF scale• Practice selectively provided based on professional judgement

Clinical Nurse Leader role • Build and lead interdisciplinary teams to implement best practice• Teams coordinate to analyze initiative longitudinally to make

improvements• Stimulate long-term enhanced quality of care

References:Asmaee Majid, S., Seghatoleslam, T., Homan, H., Akhvast, A., & Habil, H. (2012). Effect of mindfulness based stress management on reduction of generalized anxiety disorder. Iranian journal of public health, 41(10), 24–28. Hoge, E. A., Bui, E., Marques, L., Metcalf, C. A., Morris, L. K., Robinaugh, D. J., Worthington, J. J., Pollack, M. H., & Simon, N. M. (2013). Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. The Journal of clinical psychiatry, 74(8), 786–792. https://doi.org/10.4088/JCP.12m08083 Hoge, E. A., Bui, E., Palitz, S. A., Schwarz, N. R., Owens, M. E., Johnston, J. M., Pollack, M. H., & Simon, N. M. (2018, April). The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Research. https://www.sciencedirect.com/science/article/abs/pii/S0165178116308472 Hölzel, B. K., Hoge, E. A., Greve, D. N., Gard, T., Creswell, J. D., Brown, K. W., Barrett, L. F., Shwartz, C., Vaitl, D., & Lazar, S. W. (2013). Neural mechanisms of symptom improvements in generalized anxiety disorder following mindfulness training. NeuroImage: Clinical. https://www.sciencedirect.com/science/article/pii/S2213158213000326?via%3Dihub Masumian, S., Ghahari, S., Beigi, Z. B., Asgharnejadfarid, A. A., & Yaghmaeezadeh, H. (2019, January 24). The Effectiveness of Mindfulness-based Stress Reduction (MBSR) in Reducing of Depression, Anxiety and Quality of Life in Women with Generalized Anxiety Disorder. Journal of Research in Medical and Dental Science. https://www.jrmds.in/articles/the-effectiveness-of-mindfulnessbased-stress-reduction-mbsr-in-reducing-of-depression-anxiety-and-quality-of-life-in-women-with-ge-5659.html

Effects of Exercise with Medication and/or Therapy for Adults with Major Depression

Background• Major Depression (MDD) is one of the most common mental health

problems in the US with more than 19 million US adults reported at least one depressive episode in 2020.

• Common treatments include antidepressants and/or behavioral intervention therapies but these are not accessible to all affected.

• Moderate-intensity exercise has been found to reduce risk of developing chronic physical conditions but also mental health conditions like depression

PurposeExamine if exercise with medications and/or therapy helps decrease depressive symptoms and improve mental health for adults with Major Depressive Disorder.

• Extensive search was conducted using PubMed • Studies were Randomized Control trials from 2015 to 2021• Keywords: major depression, physical activity, aerobic exercise, exercise• Particpants were adults with diagnosis of Major Depressive Disorder

Methods

Implications for Nursing Practice• Patient safety during exercise is extremely important and needs to

always be considered during moderate-intensity workouts.• The use of the multidisciplinary team (psychiatrists, primary care,

PT/OT) can be beneficial in developing a safe, efficient, and effective exercise routine that patients with depression can easily implement and follow.

• Many different moderate intensity workouts can be used such as running, walking, exercise machines, or classes.

• Patients should be participating in at least 20 minutes of moderate-intensity exercise three days a week, along with their other treatments, for the intervention to be effective

• Moderate-intensity exercise, along with medications and/or therapy, helped patients reduce their depressive symptoms and allowed some patients to achieve remission from their depression

• Adults talking Sertraline along with exercising were found to have significant reductions in symptoms• The more the patient can tailor the exercise routine to their liking, the more likely they will be compliant.• More research is needed to see if exercise will benefit patients taking other kinds of antidepressants or using other types of therapies.• Having free and enjoyable exercise interventions can give more people a chance to manage their depressive symptoms.

Summary & Conclusion

Authors Purpose Sample Intervention Results

Tasci et al. (2019)

Examine effects of physical activity on those with diagnosed depression

Admitted adult patients (ages 18-65) diagnosed with Major Depressive

disorder

Intervention: Brisk walking for at least 30 minutes a day, four days a week, for 12 weeks along with antidepressants.

Control: Antidepressant medication only

At the 6-week mark, the intervention group were showing mild depressive symptoms (p=0.007) and by12 weeks, intervention showed no depression while the control showed mild depression (p=0.006).

Belvederi Murri et al.

(2015)

Examine if antidepressant therapy plus physical exercise

leads to better outcomes for major depression

Adults 65-85 years old with diagnosis of major

depressive disorder

Intervention: Sertraline + 24 weeks of supervised group exercise sessions three times a week

Control: Sertraline only

Remission rates for depression were significantly higher in the two intervention groups compared to control (p=0.22)..

Olson et al. (2017)

Examine the effects of a moderate-intensity exercise

for those with Major Depressive Disorder (MDD)

Adults ages 18-30 years with diagnosis of MDD using antidepressants

Intervention: Three sessions/week for 8 weeks of 45 minutes of continuous moderate exercise performed on a treadmill

Control: Three sessions/week for 8 weeks of 45 mins of light-intensity

Significant reduction in depressive symptoms in the exercise group after 8 weeks (compared to control (p=0.01).

Buschert et al. (2019)

Examine the effects of an exercise program on severity of depression in

patients suffering from Major Depression (MDD)

Psych inpatients at German hospital with

MDD diagnosis

Intervention: 30-minute endurance training for four weeks incorporating outdoor walking, Nordic walking, or running

Control: 4weeks of 30-minute occupational or art therapies

Significant improvement in affective symptoms over time for both the Beck Depression Inventory-II (p=0.001).

Kerling et al. (2015)

Assess if exercise intervention is feasible in severely depressed patients and if exercise has any effect on depressive

symptoms

Adults over 18 years with MDD and who were

being treated by the Hanover Medical School.

Intervention: 45-minute moderate intensity workout over six weeks & normal MDD treatment

Control: Normal MDD treatment and daily activity program

Exercise group had at least a 50% reduction depressive symptom compared to those in the control group (p=0.037).

Carneiro et al.

(2015)

Measure effect of exercise program with antidepressants

for women with depression

Women ages 18-16 with MDD diagnosis

Intervention: 16 weeks of moderate-intensity exercise sessions along with treatment as usual

Control: Treatment as usual (meds or therapy)

Exercise group showed significant improvement in mean depression scores for the BDI-II compared to control (34.89 vs. 49; p=0.031).

Mairead PaxtonUniversity of Maryland School of Nursing

I would like to thank Debra Scrandis, PhD, FNP-BC, FPMHNP-BC for being my reader and her assistance throughout this process.

Acknowledgements

Citations

Table of Evidence

Julie Ruhe, UMSON, CNL Student Reader: Elizabeth Galik, PhD, CRNP, FAAN, FAANP

Background

Methods

Evidence Summary

Implications for Nursing Practice & Role of CNL

Summary & Conclusion

Reference List

Alzheimer disease and related dementias (ADRDs) are the most common forms of dementia.Patients diagnosed with ADRD frequently exhibit behavioral and psychological symptoms such as depression, anxiety, aggression and agitation.The first line treatment for behavioral and psychological symptoms of dementia (BPSD) are non-pharmacological interventions.Many treatments are still focused on pharmacologic interventions including antipsychotics and other sedative-hypnotics.These pharmacologic interventions have been shown to be largely ineffective, with significant side effects that can often worsen quality of life for persons with dementia.

Purpose: To evaluate the body of evidence regarding the impact of music therapy on BPSD for long-term care residents with dementia to determine if there is sufficient evidence for implementation of this non-pharmacological approach to clinical practice.

Databases used: Medline & PubMedKeywords used: Dementia, music therapy, nursing home, Alzheimer's diseaseInclusion criteria: Articles published after 2016, dementia patients, long-term care facilities, RCTs and/or intervention studies as long as patient outcomes were measured.Exclusion Criteria: Older than 5 years, duplicates, at-home care A total of six articles were reviewed.

All six articles coincide with one another: Music therapy improves behavioral and psychological symptoms of patients with ADRD.All studies revealed statistically significant results (p<0.05) that music therapy improved aggression, agitation and depression.Music therapy is safer, less expensive and improves quality of life.

IMPROVEMENTS:

More research needs to be conducted related to implementing and sustaining music therapy in practice as there are many barriers.More randomized controlled trials (RCT)Larger sample sizesLonger studiesFixed music intervention timesBehavioral and psychological symptoms need to be measured through the same measurement tool that is proven to have good reliability and validity to obtain comparable results.

The clinical nurse leader (CNL) can use the plan, do, study, act (PDSA) methodology to facilitate implementation.The CNL can ensure that interdisciplinary collaboration is occurring as it is essential element of any environmental intervention.There are many barriers to implementing music therapy such as:• Funding• Equipment• Time• Training

It is important for the CNL to stay up-to-date on evidence-based practices of music therapy to ensure best practice and find solutions to barriers.

McCreedy, E. M., Yang, X., Baier, R. R., Rudolph, J. L., Thomas, K. S., & Mor, V. (2019). Measuring Effects of Nondrug Interventions on Behaviors: Music & Memory Pilot Study. Journal of

the American Geriatrics Society, 67(10), 2134–2138. https://doi.org/10.1111/jgs.16069

Onieva-Zafra, Maria, Hernandez-Garcia, Laura, Gonzalez-del-Valle, Maria, Parra-Fernandez, Maria & Fernandez-Martinez, Elia. (2018). Music Intervention With Reminiscence Therapy and Reality Orientation for Elderly People With Alzheimer Disease Living in a Nursing Home: A Pilot Study. Holistic Nursing Practice, 32, 43-50. https://doi.org/10.1097/HNP.0000000000000247

Ray K., & Götell. E. (2018). The Use of Music and Music Therapy in Ameliorating Depression Symptoms and Improving Well-Being in Nursing Home Residents With Dementia. Front Med

(Lausanne). 5(287). doi: 10.3389/fmed.2018.00287

Ray, K. D., & Mittelman, M. S. (2017). Music therapy: A nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia. Dementia

(London, England), 16(6), 689–710. https://doi-org.proxy-hs.researchport.umd.edu/10.1177/1471301215613779

Thomas, K. S., Baier, R., Kosar, C., Ogarek, J., Trepman, A., & Mor, V. (2017). Individualized Music Program is Associated with Improved Outcomes for U.S. Nursing Home Residents with Dementia. The American Journal of Geriatric Psychiatry : Official Journal of the American Association for Geriatric Psychiatry, 25(9), 931–938. https://doi-org.proxy-hs.researchport.umd.edu/10.1016/j.jagp.2017.04.008

Werner J, Wosch T, Gold C. Effectiveness of group music therapy versus recreational group singing for depressive symptoms of elderly nursing home residents: Pragmatic trial. Aging Mental

Health 21(2):147-155. doi: 10.1080/13607863.2015.1093599

Article 1

• Purpose: Can personalized music reduce agitation and aggression?

• Agitation: Decreased; ABMI score was 4.1 at baseline. With music, ABMI decreased to 1.6 (p<.01). CMAI decreased with music from 61.2 to 51.2 post-intervention (p<.01).

• Aggression: MDS-ABS decreased from 0.8 to 0.7.

Article 2

• Purpose: Can the use of combination music interventions promote well-being (depression & anxiety)?

• Depression: Improved- Goldberg test scores were found to be statistically significant for depression (P = .01).

• Anxiety: Not statistically significant (p=.82).

Article 3

• Purpose: Can music intervention led by a CNA improve depression and well-being?

• Depression: Significantly decreased (p≤0.001).

• Well-being: Video analysis showed improved well-being (p=0.001).

Article 4

• Purpose: Can the implementation of music therapy improve depressive symptoms, agitation and wandering?

• Depression: Reduced from baseline following music therapy (p<.001).

• Agitation: Reduced from baseline (p<.05).

• Wandering: No change.

Article 5

• Purpose: Can various music interventions increase rates of anti-psychotic and anxiolytic medication discontinuation, reductions in BPSD, and improvements in mood?

• Reduction in antipsychotic and anxiolytic medication and a reduction in behavioral problems (56.5%).

• Aggression: Decreased from an ABS score of 0.84 to 0.74.

• Mood: No significant changes.

Article 6

• Purpose: Can interactive music therapy and recreational group singing improve depression?

• Depression: Music therapy decreases depressive symptoms in the elderly in nursing homes compared to recreational singing (p<0.001).

• Geropsychiatric specialists found an increase in happiness (50%), increase in attention and extrinsic motivation, decrease in agitation and aggressive behavior.

Can the Implementation of Music Therapy Improve Behavioral and Psychological Symptoms of

Dementia (BPSD) for Patients with Alzheimer Disease Related Dementia (ADRD)?

SignificanceGlobally, there are 35.6 million people living with dementia and it is expected to triple by 2050.About 39.6% live in long-term care facilities with the most prevalent occurring in nursing homes (47.8%).

Light Therapy Improves Sleep Disturbance in Patients with DementiaAbby Gillum, BS, CNL student | University of Maryland School of Nursing

Methods• A search was conducted through the PubMed

and CINAHL databases.• Search terms included: “dementia”, “sleep disturbance

treatment”, “light therapy AND “dementia”, “light therapy” and “sleep disturbance” and “dementia.”

• Articles were included from 2015 to 2021• After duplicates were removed, five articles were

examined for review.

Implications for Nursing and CNL Role• The CNL can advocate for light therapy to be used as part of

a comprehensive approach to improve sleep outcomes for patients with dementia.

• Team development is required to utilize light therapy interventions effectively. Including mentoring and coaching members of the long term care team in all aspects of sleep management.

• Working with individual providers and patients to optimize dose, frequency and lux levels to improve sleep metrics.

Summary and Conclusion• Light therapy improves quality and quantity of sleep

and decreases agitation and daytime sleeping, but is inconclusive to what extent these symptoms decrease.

• Therapeutic effects are seen at lux levels > 1000 delivered via light box for a minimum of 1 hour daily, preferably in the morning.

• Higher lux levels (10,000+) used for sleep improvements have mixed findings. More research is indicated for individually tailored light prescriptions in dementia management.

• Evidence supports the use of light therapy for improving sleep symptoms for mild to moderate Alzheimer’s disease, but inconclusive for mixed and vascular dementia.

• Combination of light therapy and pharmacologic sleep management has not been well studied and further research is indicated.

ReferencesDimitriou, T. & Tsolaki, M. (2017). Evaluation of the efficacy of randomized controlled trials of sensory stimulation interventions for sleeping disturbances in with dementia: a systematic reviepatientsw. Retrieved from https://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pmc/articles/PMC5364002/

Hjetland, G., Pallesen, S., Thun, E., Kolberg, E., Nordhus, I., & Flo, E. (2020). Light interventions and sleep, circadian, behavioral, and psychological disturbances in dementia: a systematic review of methods and outcomes. Retrieved from https://www-sciencedirect-com.proxy-hs.researchport.umd.edu/science/article/pii/S1087079220300538?via%3Dihub

Mitolo, M., Tonon, C., La Morgia, C., Testa, C., Carelli, V., & Lodi, R. (2018). Effects of light treatment on sleep, cognition, mood, and behavior in alzheimer’s disease: a systematic review. Retrieved from https://www-karger-com.proxy-hs.researchport.umd.edu/Article/FullText/494921

O’Caoimh, R., Mannion, H., Sezgin, D., O’Donovan, M., Liew, A., & Molloy D. (2019). Non-pharmacological treatments for sleep disturbance in mild cognitive impairment and dementia: A systematic review and meta-analysis. Retrieved from https://www-sciencedirect-com.proxy-hs.researchport.umd.edu/science/article/pii/S0378512219301331?via%3Dihub

Porter, V., Buxton, W., & Avidan, A. (2015). Sleep, cognition and dementia. Retrieved from https://link.springer.com/article/10.1007/s11920-015-0631-8

Rose, K. & Fagin, C. (2011). Sleep disturbances in dementia: what they are and what to do. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3062259/#:~:text=Sleep%20disturbances%20occur%20frequently%20in%20persons%20with%20dementia%2C%20oftentimes%20increasing,by%20older%20adults%20with%20dementia.

Sekiguchi, H., Iritani, S., & Fujita, K. (2017). Bright light therapy for sleep disturbance in dementia is most effective for mild to moderate Alzheimer’s type dementia: a case series. Retrieved from https://onlinelibrary-wiley-com.proxy-hs.researchport.umd.edu/doi/full/10.1111/psyg.12233

Wennburg, A., Wu, M., Rosenburg, P., & Spira, A. (2017). Sleep disturbance, cognitive decline and dementia; A review. Retrieved from https://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pmc/articles/PMC5910033/

AcknowledgementsI would like to thank Dr. Sherrie Lessans, PhD, RN for being my reader and assisting me through this process.

Authors Purpose Sample Intervention Results

Sekiguchi, H., Iritani, S., & Fujita, K.

(2017)

This case-series in Japan explores the effects of bright light therapy on sleep disturbance in clients dementia.

17 patients from OkehazamaHospital Fujita Mental Care Center with Alzheimer’s, Vascular dementia, and LeweyBody dementia. Alzheimer’s being the majority diagnosis.

Patients sat in front of a light box for an hour a day in the morning (9am – 10am) for two weeks. The light box was placed at eye level at 5000 lux

The patients that had mild to moderate Alzheimer’s responded better to the treatment shown through improvement of sleep disturbance symptoms.

Dimitriou, T. & Tsolaki, M.

(2017)

This systematic review evaluates nonpharmacological sensory stimulation interventions for ways to reduce sleep disturbances in patients with dementia.

760 participants were included who met a DSM-IV diagnosis for dementia. Majority had Alzheimer’s, but also included vascular and mixed dementia.

Studies included lasted from 10 days to 12 weeks. One study lasting 3.5 years. Most of the trials used light boxes from 5000 – 10,000 lux with a minimum of an hour in front of the light. Time of day was not always specified

Concluded light therapy works for patients with Alzheimer’s. Saw a decrease in nightmares and an increase in quality and duration of sleep.

Mitolo, M., Tonon, C., La Morgia, C., Testa, C.,

Carelli, V., & Lodi, R. (2018)

This systematic review examines the effects of light treatment on patients with Alzheimer’s disease (AD) and how it effects their sleep, cognition, mood, and behavior.

32 articles were included, all AD patients.

Morning light was the majority intervention for an hour minimum through the use oflight boxes. Lux levels were not stated.

Mild to moderate AD patients showed a greater response to the therapy through a decrease in sleep disturbance symptoms, like daytime sleeping. Severe AD did not respond.

Hjetland, G., Pallesen, S., Thun, E.,

Kolberg, E., Nordhus, I., & Flo, E. (2020).

This systematic review evaluates light therapy as a nonpharmacological treatment option for sleep disturbances in patients with dementia.

21 studies were included, all patients had a dementia diagnosis with a majority being AD.

Of the 21 studies, 8 used light therapy in the morning and 9 used it throughout the day. Therapy was done for an hour minimum, one time/day, at 1000 lux or higher at eye level. 14 of the studies used light boxes.

Inconsistent results were found. 9 of the studies found improvements in sleep patterns, but overall the low sample size within each study lead to unclear or insignificant results.

O’Caoimh, R., Mannion, H., Sezgin, D., O’Donovan, M., Liew, A.,

& Molloy D. (2019).

This systematic review and meta-analysis investigates non-pharmacological treatments for sleep disturbance in dementia.

48 articles were examined. Patients had a diagnosis of dementia or mild cognitive impairment. Majority had moderate to severe dementia.

Studies lasted from 1 to 10 weeks with an hour minimum in front of light. Most of the articles used light boxes in the morning. Lux levels were not specified.

81.5% of the studies concluded that light therapy improved objective and/or subjective outcomes of sleep. Majority of the trials, that assessed BLT, show significant changes in the participants sleep-wake cycle and duration of nocturnal sleep

Table of Evidence• Sleep disturbances are more prevalent in patients with

dementia due to the brain changes and results of aging. (Rose & Fagin, 2011).

• 60 to 70% of people with this diagnosis have poorer disease outcomes due to sleep disturbances. (Wennburg, et al. 2017).

• Sleep disruptions may appear as insomnia, wandering, frequent nighttime awakenings, more daytime sleepiness, agitation (Porter, Buxton & Avidan, 2015)

• Light therapy is a nonpharmacological option that can be implemented easily and help induce better quality and quantity of sleep. Most commonly through a light box at higher lux levels than normal.

• Light exposure can help the body recognize a more natural sleep-wake cycle.

• Purpose: Evaluate the effectiveness of light therapy on patients with dementia that suffer from sleep disturbances

Background and Significance

https://www.google.com/search?q=light+box+for+therapy+dementia&tbm=isch&ved=2ahUKEwj9obqS9I_wAhUHMt8KHYiNC3QQ2cCegQIABAA&oq=light+box+for+therapy+dementia&gs_lcp=CgNpbWcQAzoECAAQHjoGC-AAQCBAeUPBzWNSAAWDIgQFoAHAAeACAAVmIAbQFkgEBOZgBAKABAaoBC2d3cy13aXotaW1nwAEB&sclient=img&ei=6WaAYL2JF4fk_AaIm66gBw&bih=721&biw=650&rlz=1C1CHBF_enUS853US853#imgrc=gpVO6HhHCca8_M

Implementing a Music Therapy Program for Alzheimer’s Care: A Comprehensive Team Approach

Jessica Brown, BA, CNL StudentUniversity of Maryland Baltimore, School of Nursing

Background & Significance

• In Alzheimer’s Disease (AD), abnormal plaques and tangles in the hippocampus prevent neural connections, resulting in memory loss and behavioral symptoms (NIA.gov, 2019).

• Behavioral symptoms in AD may include agitation, anxiety, and aggression. In 2012, 80-90% of AD patients in residential care suffered from behavioral symptoms (Ray & Mittelman, 2017). Nursing staff must be prepared to address these behaviors in a caring, compassionate and effective way.

• Members of the care team for AD patients have limited non-pharmacological resources to help reduce behavioral symptoms, causing them to turn to restraints and medications more frequently than may be necessary (Hoffman & Hahn, 2014).

• Music therapy is the use of music activities to treat the behavioral, cognitive, emotional or physical needs of a patient (AMTA, 2021). Music therapy is a common therapeutic modality in residential care.

• Music therapists typically provide 1-2 hours of treatment per week to residents. Current evidence shows music therapy to be effective for the reduction of behavioral symptoms in AD and that increasing its use could reduce these symptoms further, provide for better patient comfort and care, and decrease the need for chemical or physical restraint.

Methods

• As the nursing staff spends more time with patients than music therapists, the following PICO question was developed: When added to weekly music therapy sessions, can music interventions led by non-music therapists, reduce agitation and anxiety in AD, compared to weekly music therapy sessions alone?

• A search of PubMed and CINAHL using the keywords “music”, “Alzheimer’s” and “behavioral” was performed. Following the exclusion of titles more than 5 years old, and adding “agitation” as a search term, 18 titles remained. The remaining titles were assessed for quality and relevance to this review. Five articles were selected.

Conclusion

• Music therapy is well established for reducing behavioral symptoms of Alzheimer’s Disease. In addition to significant decreases in anxiety, depression and agitation, frequent music therapy interventions are shown to decrease the need for anti-psychotic medications.

• Evidence supports that non-music therapists can participate in music interventions as part of a comprehensive team when sufficiently trained, and as a complement to routine music therapist-led sessions.

• The evidence supporting training for nurses is inconsistent in duration and method and should be studied further.

• The CNL should arrange training for members of the care team, to enable them to provide appropriate music interventions under the supervision of the staff music therapist. The goal of this team approach to care would be to amplify the effects of music therapy and provide greater resident safety and comfort.

Implications for Nursing Practice

•A Clinical Nurse Leader (CNL), should advocate for the hiring of a staff music therapist if there is not one currently working in the facility. •The CNL, as a lateral integrator and educator, should collaborate with a music therapist to develop and grow the music therapy team through training in music interventions.•Board Certified Music Therapists are highly skilled in manipulating musical elements to elicit change in a client. Not all techniques and methods will be appropriate for non-music therapists to use. However, some can be adapted and effectively used by members of the care team. The following is an example:

o Nursing staff should determine musical preferences as part of admission and have recorded music available to residents.

o Staff members can encourage a resident to listen to a preferred playlist and encourage reminiscence and conversation after listening.

•The CNL should be responsible for developing a measurement tool to evaluate the effectiveness of the implemented music therapy program.

Acknowledgment

I would like to thank Dr. Sherrie Lessans, RN, PhD for serving as faculty reader for this project

References

American Music Therapy Association. (2021). What is Music Therapy? https://www.musictherapy.org/

Gallego, M. & Garcia, J. (2017). Music therapy and Alzheimer's disease: Cognitive, psychological, and behavioural effects. Neurologia, 32(5), 300-308. 10.1016/j.nrl.2015.12.003

Giovagnoli, A., Manfredi, V., Schifano, L., Paterlini, C., Parente, A. & Tagliavini, F. (2018). Combining drug and music therapy in patients with moderate Alzheimer's disease: a randomized study. Neurological Sciences: Official Journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 6(39), 1021-1028. 10.1007/s10072-018-3316-3

Hofmann, H. & Hahn, S. (2014). Characteristics of nursing home residents and physical restraint: a systematic literature review. Journal of Clinical Nursing, 23, 3012-3024. https://doi.org/10.1111/jocn.12384

Kirkham, J., Sherman, C., Velkers, C., Maxwell, C., Gill, S., Rochon, P. & Seitz, D. (2017). Antipsychotic Use in Dementia: Is There a Problem and Are There Solutions? The Canadian Journal of Psychiatry, 62(3), 170-181. 10.1177/0706743716673321

National Institute on Aging (2017). Coping with Agitation and aggression in Alzheimer’s Disease. https://www.nia.nih.gov/health/coping-agitation-and-aggression-alzheimers-disease

Ray, K. & Götell, E. (2018). The Use of Music and Music Therapy in Ameliorating Depression Symptoms and Improving Well-Being in Nursing Home Residents With Dementia. Frontiers in Medicine, 5, 287. 10.3389/fmed.2018.00287

Ray, K. & Mittelman, M. (2017). Music therapy: A nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia. Dementia, 16(6), 689-710. 10.1177/1471301215613779

Thomas, K., Baier, R., Kosar, C., Ogarek, J., Trepman, A. & Mor, V. (2017). Individualized Music Program is Associated with Improved Outcomes for U.S. Nursing Home Residents with Dementia. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 25(9), 931-938. 10.1016/j.jagp.2017.04.008

Literature ReviewGiovagnoli, et al. (2018), compared the effects of music and medication and medication alone for Alzheimer’s symptoms. Music therapy two times per week for 24 weeks was added to intervention group participants who were on a regular pharmacological treatment of 20mg memantine daily for Alzheimer’s symptoms. The music therapy sessions consisted of guided improvisation on simple rhythmic and melodic instruments. Results of the study showed that the music therapy group demonstrated significantly fewer symptoms of depression and anxiety.

Gomez-Gallego & Gomez-Garcia (2017), 42 participants with mild to moderate AD were assessed for memory, orientation, depression and anxiety at baseline. Participants then took part in music therapy two times per week for six weeks. Results showed that participants’ scores in depression and anxiety were already improved from baseline at week 3 and continued to improve to week six in the mild AD group. The difference in scores for memory and orientation were also improved at week six in the moderate group. The study suggests that music therapy is effective for behavioral symptoms, however the greater the severity of AD, the greater amount of music therapy required to bring about a change. Further study would be required with individuals with severe AD and music therapy.

Ray & Gotell (2018) examined the effectiveness of music interventions provided by CNAs when trained by credentialed music therapists. This study used music therapy conducted by professional music therapists three times per week for two weeks. Following the initial music therapy sessions, CNAs in the facility were trained for three days by music therapists in simple music techniques, then led music-based interventions three times weekly for two weeks with participants. Depressive symptoms were measured using the Mean Cornell depression scale. Participants’ scores decreased significantly from a baseline average of 8.29 to a score of 5.31 following music therapist. After a 2-week absence from music therapy, the average score increased slightly to 6.34 and appeared to stabilize with the interventions by the CNAs at an average of 6.56.

Thomas, et al. (2017) examined the ability of music interventions to reduce the need for anxiolytic and antipsychotic medications. Following a training in a technique called Music & Memory, the intervention group received CNA-led music interventions. The intervention group saw an increase in discontinuance of antipsychotic medications from 17.6% to 20.1%. Additionally, behavioral symptoms decreased by about 6% in the intervention group.

Ray & Mittelman (2017) sought to determine if music therapy could minimize neuropsychiatric symptoms of AD. Measurements for wandering, agitation and depression were taken at baseline. Participants engaged in music therapy three times per week for two weeks. Measurements were taken again after the two weeks of intervention, and then two weeks post intervention.. Agitation and depression scores decreased significantly from baseline to post-intervention and remained stable for the two weeks without intervention.