People living with dementia may benefit from talking therapies

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Cambridge scientists have shown that it is possible to spot signs of brain impairment in patients as early as nine years before they receive a diagnosis for one of a number of dementia-related diseases.

In research published today in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, the team analysed data from the UK Biobank and found impairment in several areas, such as problem solving and number recall, across a range of conditions.

The findings raise the possibility that in the future, at-risk patients could be screened to help select those who would benefit from interventions to reduce their risk of developing one of the conditions, or to help identify patients suitable for recruitment to clinical trials for new treatments.

There are currently very few effective treatments for dementia or other neurodegenerative diseases such as Parkinson’s disease. In part, this is because these conditions are often only diagnosed once symptoms appear, whereas the underlying neurodegeneration may have begun years – even decades – earlier.

This means that by the time patients take part in clinical trials, it may already be too late in the disease process to alter its course.

Until now, it has been unclear whether it might be possible to detect changes in brain function before the onset of symptoms. To help answer this question, researchers at the University of Cambridge and Cambridge University Hospitals NHS Foundation Trust turned to UK Biobank, a biomedical database and research resource containing anonymised genetic, lifestyle and health information from half a million UK participants aged 40-69.

As well as collecting information on participants’ health and disease diagnoses, UK Biobank collected data from a battery of tests including problem solving, memory, reaction times and grip strength, as well as data on weight loss and gain and on the number of falls.

This allowed them to look back to see whether any signs were present at baseline – that is, when measurements were first collected from participants (between five and nine years prior to diagnosis).

People who went on to develop Alzheimer’s disease scored more poorly compared to healthy individuals when it came to problem solving tasks, reaction times, remembering lists of numbers, prospective memory (our ability to remember to do something later on) and pair matching. This was also the case for people who developed a rarer form of dementia known as frontotemporal dementia.

People who went on to develop Alzheimer’s were more likely than healthy adults to have had a fall in the previous 12 months. Those patients who went on to develop a rare neurological condition known as progressive supranuclear palsy (PSP), which affects balance, were more than twice as likely as healthy individuals to have had a fall.

For every condition studied – including Parkinson’s disease and dementia with Lewy bodies – patients reported poorer overall health at baseline.

First author Nol Swaddiwudhipong, a junior doctor at the University of Cambridge, said: “When we looked back at patients’ histories, it became clear that they were showing some cognitive impairment several years before their symptoms became obvious enough to prompt a diagnosis. The impairments were often subtle, but across a number of aspects of cognition.

“This is a step towards us being able to screen people who are at greatest risk – for example, people over 50 or those who have high blood pressure or do not do enough exercise – and intervene at an earlier stage to help them reduce their risk.”

Senior author Dr Tim Rittman from the Department of Clinical Neurosciences at the University of Cambridge added: “People should not be unduly worried if, for example, they are not good at recalling numbers. Even some healthy individuals will naturally score better or worse than their peers. But we would encourage anyone who has any concerns or notices that their memory or recall is getting worse to speak to their GP.”

Dr Rittman said the findings could also help identify people who can participate in clinical trials for potential new treatments. “The problem with clinical trials is that by necessity they often recruit patients with a diagnosis, but we know that by this point they are already some way down the road and their condition cannot be stopped. If we can find these individuals early enough, we’ll have a better chance of seeing if the drugs are effective.”

Funding: The research was funded by the Medical Research Council with support from the NIHR Cambridge Biomedical Research Centre.


How do talking therapies work?

Talking therapy sessions are delivered by a professional, such as a counsellor, a clinical or counselling psychologist, a psychotherapist, or a psychiatrist. People can have some types of talking therapy over the telephone or online. This includes counselling and cognitive behavioural therapy (CBT).

The approach to therapy will be adapted to each person. It will be based on them and the therapist working together to find out what might be causing the person’s problems, as well as ways to manage these problems.

Successful therapy depends on developing a trusting relationship between the person and the therapist. It is important that the person is comfortable with the therapist’s approach and manner. Their relationship is confidential. This means the therapist won’t tell anyone what they discuss during therapy. There are some exceptions to this, which the therapist should explain during the first meeting. For example if the person with dementia gives their consent, they may be accompanied and supported in the sessions by a family member.

Listen to our helpsheet below for a summary of talking therapies and the other main non-drug treatments for dementia:

Benefits of talking therapies for people with dementia

Talking therapies can be effective for people in the early to middle stages of dementia. Talking therapies are unlikely to help if a person is in the later stages. This is because they are likely to have problems with their attention, communication, understanding and memory, which are all key to being able to benefit from talking therapies. However, there are other ways to support people in the later stages of dementia, such as through sensitive listening or sensory stimulation. See our advice on communicating in the later stages of dementia.

Talking therapies can give a person with dementia the chance to speak openly about their feelings, including how they feel about a recent diagnosis. This can help them adjust and live with their condition more successfully. They might find it helpful to discuss problems with a therapist rather than their friends or family members. A therapist can give them a safe space to explore the reasons why they feel how they do. This can be comforting. It can also help them maintain healthy relationships with their friends and family members.

There is evidence that having talking therapy over several weeks may reduce depression and anxiety in people in the early stages of dementia. The therapy needs to be adapted to the person’s level of communication, understanding and memory. It’s therefore likely to be most effective if the therapist has experience of working with people with dementia as well as a good understanding of the condition.

Suitable talking therapies are not always available in the person’s local area. People in care homes may find it particularly difficult to access talking therapy services. See ‘How to find a therapist’ below for advice on how to do this.

Types of talking therapy

There are many different types of talking therapy. The main ones are explained below. The most suitable type will depend on what the person wants to get out of it, their stage of dementia and the symptoms they are having.

Counselling

Counselling is the general term for a range of talking therapies, including individual, group and couples sessions. It aims to help a person better understand their problems and then explore ways to manage them. A counsellor won’t give the person ‘answers’. They will give them time and guidance to look at their problems with a professional.

Counselling is often used to help a person cope with events they’ve found difficult. It can be particularly helpful for people who have recently been diagnosed with dementia. Being assessed for suspected dementia can be confusing, stressful and make the person feel anxious.

Many people with dementia struggle to make sense of their diagnosis and how their life is changing. They may feel lost, confused, vulnerable or anxious. Counselling can help them manage these worries. It can make them feel less depressed and hopeless, and help them accept their diagnosis.

Psychotherapy

Psychotherapy is a term for another range of talking therapies. The type of psychotherapy that a person is offered will depend on what is most appropriate for them.

A psychotherapist will help a person understand how their personality, beliefs and experiences influence their thoughts, feelings, relationships and behaviour. This can change the way they think and behave. It can also help them deal with problems and difficult situations more successfully.

Psychotherapy can help people with dementia feel less depressed and anxious. This can help them maintain a good quality of life and cope with their condition.

Cognitive behavioural therapy (CBT)

This is one specific type of psychotherapy. Cognitive behavioural therapy (CBT) is based on the fact that the way we think about something (our ‘cognition’) affects how we feel and then how we behave.

CBT for depression or anxiety is most suitable for people in the earlier stages of dementia. They may have fewer difficulties with their memory, communication and reasoning. They are also usually more aware of their condition and their own thoughts and emotions than a person in the later stages of dementia. This will mean they can effectively engage with the therapy.

CBT sessions may need to be adapted to meet the specific needs of the person with dementia. This might include having shorter sessions, using memory aids (such as cue cards or digital devices) and summarising ideas throughout the sessions. If the person with dementia agrees, a family member or close friend may attend sessions with them. This supporter can also help them use CBT strategies outside of the sessions.

How can talking therapies help carers?

Dementia is a complex, unpredictable and progressive condition. As a result, caring for a person with dementia is unlike caring for a person with other conditions.

Caring can be very rewarding and fulfilling. It can also be very stressful, particularly if there are no or few other people who can help. You may suppress your feelings to protect the person you’re caring for and become socially isolated and sleep-deprived. This reduces the ability to cope with negative feelings and stress. As a result, it is common for carers to feel anxious and depressed.

When you are caring for a person with dementia it’s important that you look after yourself and take regular breaks. For more information see our booklet 600, Caring for a person with dementia: A practical guide.

Carers may also find talking therapies useful. Therapy can help to explore your feelings in private. This may be especially important when you’re making decisions about how to look after the person with dementia. For example if they move into residential care you may need time to adjust and learn to accept that you now have less responsibility for them. Therapy can also help if you are feeling guilty or embarrassed about how you feel about the person with dementia.

Counselling

Counselling can help carers be more aware of their thoughts and behaviours. It gives them a chance to think about how to manage their reactions and cope more effectively.

Counselling can also help carers think about the impact their thoughts and behaviours may have on the person with dementia. The way a carer approaches a person with dementia will affect how the person feels and behaves, both positively and negatively. If a carer is stressed and becomes short-tempered, the person with dementia will be more likely to feel anxious, depressed or develop challenging behaviours. The carer may then feel guilty as a result.

Rather than face-to-face sessions, telephone counselling may be more convenient for people who have caring responsibilities. Online counselling and therapy through apps that allow video calls may also be available.

Caring for a person with dementia can affect personal relationships. Therefore partners may find relationship counselling or couples therapy helpful. Relate offers relationship counselling – see the section ‘Other resources’ for details. Some carers also find it very helpful to speak to professionals who specialise in dementia care, such as an Admiral Nurse (available in some parts of the UK but not everywhere).

There is more information on Admiral Nurses on the Dementia UK website.

Psychotherapy

Psychotherapy can make carers feel less distressed. Carers who have depression may find CBT particular helpful, including face-to-face and telephone sessions.

It’s very important that the therapy is tailored to the individual and their circumstances. Computerised CBT (cCBT) packages for carers generally aren’t specific to each individual. However cCBT may still be helpful and should be considered if it is the only available option, such as when a carer doesn’t have much time available for therapy. 

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Former carers

If the person with dementia has died, talking therapies can help carers to cope and manage upsetting and stressful thoughts. Therapy may also help them to accept the past and plan for the future. For example, it can help someone to come to terms with their new situation and any loss they may feel. Some talking therapies are specifically focused on helping people deal with losing someone close to them, such as bereavement counselling or bereavement CBT.

What to look for in a therapist

It is important for anyone who is having therapy to feel comfortable with their therapist. The relationship will depend on a number of factors, including the personalities of both the person and the therapist.

For both someone with dementia or a carer, it is likely to be most helpful to find a therapist who has experience or an understanding of the condition.

It is important to meet the therapist face to face (for sessions in person) or to speak to them on the telephone to have a chat and see whether they seem suitable. It is also important to check that the therapist:

  • is accredited by the relevant professional body (see the section ‘Other resources’)
  • abides by a professional code of ethics
  • has regular professional supervision to make sure their practice is safe and ethical
  • explains their approach, confidentiality, fees (if applicable), length of sessions and responsibilities (theirs and the person who is having the therapy) before committing to sessions.

How to find a therapist

Many GPs can give people details about therapists in the local area. Some GP surgeries also have talking therapy services based in their practices. 

Many of the talking therapies for depression and anxiety mentioned in this section are available through an NHS England programme called Improving Access to Psychological Therapies (IAPT) (see the section ‘Other resources’ for more detais). A person’s GP can refer them to a local IAPT service. The service will assess them and offer support. This could include signposting to relevant activities, self-help materials or psychological therapies. Some IAPT services also let people refer themselves to the service without having to go through their GP.

Talking therapies that people access through the NHS are usually free of charge, although there can be a long waiting list.

Some local charities, faith groups and other organisations may also offer counselling or informal support services. A person’s GP or local social services department may have more information about this. Or, use our Dementia Directory to find local support services for people with dementia and carers

Another option is to find a private therapist. A person’s friends and family members may be able to recommend a therapist they have had sessions with. Someone who has a lower income will generally be charged less than a person who can afford to pay the full rate.

resource link : https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/talking-therapies


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Studies of genetic dementia cohorts suggest that disease biomarkers change in neurodegenerative diseases years before symptoms are obvious. In genetic frontotemporal dementia (FTD), structural brain changes are detectable 10 years before symptom onset,4-6 with pre-symptomatic alterations in functional brain network organization7 and microRNA (miRNA) expression.8 In genetic Alzheimer’s disease (AD), CSF and neuroimaging changes may be seen 15 to 25 years before symptom onset.9-11

The pre-diagnostic phase of sporadic neurodegenerative disease is more challenging to assess. There is indirect evidence that Aβ neuropathology is present several years before symptom onset in sporadic AD and is associated with cognitive decline.12 There is also evidence for a pre-symptomatic reduction in the monoaminergic nuclei MRI (magnetic resonance imaging) signal.13

These studies suggest early pathological changes, but it remains less certain whether this translates into impaired cognition or day-to-day function. There is evidence for pre-diagnostic accelerated forgetting in familial AD mutation carriers,14 whereas apathy and executive dysfunction appear early in individuals who carry mutations for FTD.5, 15

However, global cognitive and behavioral functions remain near normal if supported by a reorganization of the brain’s functional network.7, 16, 17 It remains unclear whether changes in cognition and physical function in sporadic neurodegenerative diseases are detectable before symptom onset and how long before a diagnosis they are identifiable.

Original Research: Open access.
Pre-Diagnostic Cognitive and Functional Impairment in Multiple Sporadic Neurodegenerative Diseases” by Nol Swaddiwudhipong et al. Alzheimer’s and Dementia

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