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<Original Article> Day Care Treatment for elderly Persons with Dementia<BR>- Evaluation of Prognosis with respect to Physicak Activity and EEG - 利用統計を見る

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Yimanashi Med.J. 13(l),l5 - 27, l998

Day Care

Evaluation and

Treatment for Elderly Persons with Dementia

Prognosis with Respect to Physical Activity and

EE(]F-Kouichi SHIRAISHI

Dopartment of'NezeroPsy(:hiat71y, }?zmanashi 1vae(li(;al dniv, exs'ity, 1J10 ShimQkato, Nakakoma, 7kemaho, }7tmanashi 409-382I,.laPan

Abstract: In elderly persons with dementia who live at home ancl exhibit troublesome behavior, clin-ical improvement is oftet} observed with day care treatmet}£ (l)CT). However, few s£udies have exam-ined the treatrnent efl'ects and mechanism. Sii)ce l)()T is labor ii}£ensive, it is necessary to select pa£ients who would optimally benefit from the treatment However, no predic£ors are avallable to facilitate the selection of patients who will most likely receive betief'it f-rom l)CT. Ii} this study, l)CT was provided to 20 patients with demei}tia, and its efl'ects on clinical symptoms were precisely evaluat--ed, ar}d physical activity and basal rhythm of electroencephalogram (EEG) were qttantita£ively ana-lyzed. The subjects were randomly divided into two groups : "Improved group" (l3 patients) ai}d "Not-improved grottp" (7 patients), based on changes ln clinical symptoms and physical ac{ivity after three months of l)CT. It} the "Improved group", troublesome behavior was diminished and night-time physical activity was reduced. Af'ter the firs£ day of l)CT, changes iR basal rhythrn of EEG were most marked ln the a2 band, Wave % Time in the a2 bat}d iRcreased in £he "lmproved group", aRd decreased in the "Not-improved group". Coi}versely, in the e l ba}}d, there was a decrease in the "Improved group" and an increase in the "Not-improved group". This suggests that analysis of basal rhythm of EEG on the f'irst day of l)CT can be a predictor of' treatment ef¥'ects three months later.

Key words: l)emen{ia, Day care treatment, l'hysical activity, EEG, l'redictoroftreatinente'ffects

INTRODUCTION

k} general, elderly persons with dementia living at home have a low level of vigilance in the daytime and sleep lightly at night. They occasionally develop alteratioi}s in conscious-ness such as deliriura and diumal rhythm dis-turbances such as reversal of day and night. Pro-vidiRg DCT for approximately six heurs iit the daytime often impreves these symptoms includ-ing troublesome behavior. Although DCT does not improve core symptoms of dementia such as deteriora£ion of cognitive f"nction,

improve-Received May gO, l997 Accepted Feb 27, l998

ments in emotion and cooperativeness are

attained. It has also beeR reported that each member of the family gained a better under-standing of the disease and their attitude

improved: i.e. they coi}ld take care of patieRts better than befbrei). Moreover, DCT has a

histo-ry of ten years or more in Europe and

America2), and it has beei} reported that in those countries DCT delayed the time when the patieRts had to be institutioRalized3). DCT also reduces the family's ecoRomical burden4). The need te establish more DCT facilities is pressing

and more institutions have recegnized this fact"-7). In Japan, DCT is now becorning one of the treatment optlons for elderly patients with

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16

dementia as an alternative to drtig treat r}ent or hospitalization8).

H[owever, DCT is labor ifltensive and it is not effbstive fbr all cases. Therefore, te use this treatment effectively it would be preferable to select patieRts who weuld gain the most beRefit from it. We previously stt}died psychophysielogi-cal aspects`') of DC ['. In the present study, we evaluated the usefulness of this treatment based on syu}ptom questioRnaire, physical activity, cliRical evaluation aBd EEG analysis, and also studied whether the effect of three menths of

DCT can be predicted from changes on EEG

after single DCT on the first day.

SUBJECTS ANI) METHODS

I Det]kilsofDCT

DCT -was provided for 6 hours per day fron} 9:30 to 15:30, 6 times a week from Menday to Saturday.. Two nurses, one occupational thera-pist and one clinical psychologist managed the £reatment of 10 to 15 patients per day oR aver-age. The daily schedule of DCT was as fo11ows: In the morning, physical exercise, ambulatory exercise, orientation traifling and vocal practice were given to all patients as a group after

check-ing vital signs. From then untiHunch time,

physical activities such as exercise with balls,

strelling and driving outdoors to expose

patients to seasonal changes were given. Lunch

was given from 11:45 to 12:45. Then the

patients were divided into small groups or

indi-viduals according to the treatment target. Karaoke (singing songs) and therapeutic games requiring finger movement such as Go (a board game) arrangement, coloring paper, tearing pictures, playing cards, and leather werk were carried out, At 15:OO, tea time, as a part of ADL

(activiti(its of daily living) traiRing, patients were

required toserve tea and refi'eshments by

them-S. Kouichi

selves.

II Subjects

TWenty elderly persons with dementia were

selected from patients eRrolled ii} DCIr for the

first time between March 1993 and September l994. Three cases were receiving medication of low-dose calcium antagonist for hypertension which was not changed during the follow-up period. The rest had not previously received medical treatment. DSM-III-R (Diagnostic aRd Statistical MaRual of Mental Disorders) was

used for the diagnosis of dementia. The subjects consisted of 6 rnen and 14 women between 58 to 92 years of age (mean 83.l years): 10 with senile dementia of Alzheimer type (SDAT), 5 vascular dementia (VD), 4 mixed type dementia (MIX) and l Alzheimer's disease (AD). The score on Hasegawa's Dementia Scale (HDS) at the first clinical examination was O-19 points (mean IO.8).

Informed consent was obtained from patients and/or their family after explaining the purpos-es of the study.

III Methods

A. Evaluation ofclinical symptems

Before and three months after initiation of DCT, the cliRical psychologist evaluated I-IDS in each patier}t as an index of cognitive function. At the same time, other cllnical evaluations were performed from the perspective of the

patient's family and medical staff. Asada's Trou-blesome Behavior Scale (TBS)i") to evaluate troublesome behavier, and Assessment of Basic Care fbr the Demented (ABCD)ii) to evaluate ADL were also conducted. TBS is a question-naire containing 14 items regarding trouble-some behavior. Score O is given when no treu-blesome behavior is observed during a I month period and score 4 is given when troublesome

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1)ay Care rrreata}ent and EEG Analysis

behavior occurs more than once a day. ABCD evaluates the degree of independei'}ce from

family members in terms of six items: ability to understaRd directions, dressing, bathing, eat-ing, personal hygiene, voiding. A score between O and S was given for each item. A higher score

means that the patient is more independent

and requires less help from the family. B. Physical activity

Physical activity was continuously riieasured by the Wrist Actigram (AMI, U. S. A)'2) for 5 days before DCT was begun, lO days after

begin-ning DCT and for l week thyee months after beginning DCT. The Wrist Actigram is an accel-eration seRsor and is a non-invasive suppleineR-tary diagnostic instrument that measures physi-cal activity by detecting acceleration of O.Ol gravity or more, in all directioRs. The Wrist Acti-gram was attached to the wrist of the Ron-domi-nant hand and covered with a bandage to pre-vent the patient from removing it. Diagrams show a 6-minute accumulation period as an epoch. For statistical analysis, average daily pkysical activity per hour for 5 contintious days before DCT (actually a 3 to 5 day average due to failure to attach the Wrist Actigram, bathing

time, e£c.) was used as baseline activity.

C. EEG analysis

EEG was recorded before (9:30) and after (15:30) DCT as follows. EEG was recerded four times in total: before DCT was given on the fust

day ("Before DCT first day"), after DCT was

glven oB the fu'st day ("After DCT first day"), before DCT was givei} on the last day after thi`ee months of treatment ("Before DCT last day") and after DCT was given on the last day after three-moRth of treatment ("Af£er DCT }ast day"). Awake EEG with closed eyes was recorded for approximately 15 minutes in eight parts:

Fpi,2, Ctx4, Oi,L,, and T:s,4, with both earlobe elec--trodes as reference electredes by the tei}-twenty

l7

electrode system. Qtiantitative EEG analysis was made with an automatic analyzer using the com--puterized wave form recognition rnethod of Shi-mazone et ali3>. Wave % Time according to the band: 6 (O.5 S 5< 4.0 Hz), e2 (4.0 $ e2 <

6.o Hz), el (6.o $ el < s.o Hz), al (s.o :$ al < 9.0 Hz), or2 (9.0 :!; ct2 < 1I.5 Hz), or3 (11.5 $ or3

< 13.0 Hz), 6I (l3.0 ;$ Bl < l8.0 I-Iz) and 62

(l8.0 ;:Sl 132 < 30.0 Hz) was quantitatively indicat-ed. In this study, we analyzed data from central

and occipital EEG. When an organic change

such as cerebral infarction was evident on brain CT scan, EEG on the more healthy side was ana-lyzed. Correlation between chaRges in basal rhythm of EEG and effects of DCT was

exam-ined.

D. Classificatien of "Improved group" and "Not-improved group"

The tweRty cases were divided inte two

groups, "Improved group" and "Not-improved

group" accordifig to the fol}owing criteria. Thir-teen patients satisfied criteria O and (il), and were classified as "Improved group".

O TBS score decreased by one point or more after three moRths of DCT.

(21) The average total count of physical activity (physical activity at nighttime from 21:Oe to 6:OO the next moming) decreased by one poiilt (one count of physical activity with an acceleration ef O.Ol gravity or more) or mere after three moiKhs of DCT. The remaining seven patients were classified as "Not-improved group".

E. Analysis of EEG changes or} first day of

DCT

Whether the effect of treatinent after three

months could be predicted from the EEG

changes before and after single DCT on the first day was investigated. Change of Wave % Time according to each band: 6, e2, el, ed, a2, ct3, 61 and B2 in the central and occipital areas was

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18 S. Kouichi

used as an index of EEG change.

E Statisticalar}alysis

The MTilcoxon test was used for statistical analysis of cliRical symptoms, physical activlty

and EEG Fisher's exact probability test was used fc)rstatistical analysis of two groups

("Improved group" and "Not-improved

group"),DiffereRces with a p value less than O.05 we re coRsidered sigRificant; those with a p value less than O.IO were considered te show a tendency,

REISUIrrS

I Case presentatien

One patient, an 85-year-eld man with mixed-type dementia, whose clinical symptoms were improved by DCT and who was observed over a long period is presented (Fig. I).

HDS was O before and after DCT. His family reported wandering and nighttime inconti-neftce. Wandering at nighttime was observed almost all night long on the night prior to the first day of DCT. Awake EEG (for l5 miRutes) was obtaiRed before DCT (9:30) and after DCT (l5:30). One to two weeks after DCT was

initiate DCT

-(9:3O--15:3O)

lst day of D.C.T, 2 nd 3rd

day

day

2nd week

4th week

6th week After 2 years of treatment Fig. I

Wandering (previous night)

Wandering

EEG

EEG

Light Sleep

A'w'ak'e' f6r Toilet

18 21 O 3 6 9 12 1518o'clock

Case (85 y. o. man, rnixed type)

TWer}ty-four hours is assjgned to the horjzoixaJ axis and physical activity is assigned to the vertical axis. The upper row indicates the behavior pa£tern at night befbre DCT was initiated, and 2, 4 and 6 weeks and 2 years after the last day of 1)CT. Physical activity was meastired as t})e frequency of ac{ion accompanied by an acceleration (}f O.OIG or more per minute. When displayed, the number of accu-mulated counts per 6 rninutes is indicated as one ¢poch. One to two Nveeks after l)CT was initiated, he woke up to use the toilet 2 or g times during £he nigh£ and this persisted f'or a{least 6 weeks. I'reb-lernatic behavior such as wand¢ring was not observed af'ter 2 years of' l)CT altheugh he rernained a light sleepe r.

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l)ay (]are Treatment and EEG Analysis 19

ed, the patien{ was sleeping better and only awakeRed to use the toilet 2 or 3 times during the night and this persisted for at least 6 weeks. The family observed that neither wandering nor incoRtlneRce occurre(l at night, aRd he was able to use the toilet indepeRdently from approxi-mately 10 days after DCT was ini£iated.

Troiible-some behavior such as war}dering was not

ebserved after the 2-year treatraent period although he remRined a light sleeper. Arverage to£al count of physical activity from 21:OO to 6:OO the next mornlng was 31,461 before DCT, but decreased to 12,334 three moRths after DCT was begun.

II CI}anges in clinical symptoms

The "Improved group" consisted of 3 mei} and 10 womeR, with meaR age of 83.0 years: 6

SDAT, 4 VD, 2 MIX and l AD. The

"Not-improved groi}p" coRsisted of8 men and 4

women, with mean age of 83.3 years: 4 SDAT, 1 VD and 2 MIX. No major bias was found except forsome differences ir} the male te female ratio.

The mean HDS score was ll.5 in the

"Improved groiip" before DCT was initiated, and decreased te ll.1 tl}ree months after £he start of treatment. HDS score was 9.6 in the

"Not-improved greup" before DCT and

decreased to 8.1 aftey three months of DCT. There were no significant differences in these

results.

In the "Improved group", ABCD score was

12.2 before treatment and l2.5 after treatment.

IR the "Not-improved group", ABCD score was

15.1 before £reatment and 12.5 after treatR}ent.

There was no significant change in the

"Impi'eved group"; however, the mean decrease of 2.6 points in the "Not-improved group" was a sigr}ificant change (Wilcoxon test, p < O.05), suggesting deterioration.

III Changes in behavior and physical activity TBS scere as aa index of troublesome behav-ior was 2S.5 before DCT in £he "Improved

group" and decreased significantly to 13.8 aftei' DCT (Wilcoxon test, p < O.Ol) (Fig. 2). Cor}-versely, TBS score of }8.0 poiRts ii} the "Not--irnproved group" before treatmei}t iRcrease(l significantly to 25.0 after treatment (Wilcoxon test, p < O.05).

rfotal physical activity t)etween 6:OO and 21:OO

was approximately 1.10 × I05 in both the

"Improved group" and the "Not-improved

group" l]>efore treatment, and did not change after three months of £reatmefit The count of total physical activity during the night (21:OO) tmtil the next merning (6:OO) in £he "Ill}proved

Fig. 2 40 35 9 o 8 co- 30 an

e

v

pto os 25 8 .E k 2o

6

6

g 15 8

6

= 9 lo

e

5

imm' * * "'l ('-' * ww'nvi o

Improved Not-Improved

TBS score in the "In)proved" and

"Not-irnproved" groups

The score for troublesoine behavior indicat-ed by TBS was 23.5 ii} the "Improvindicat-ed group" before l)CT was initlated and decreased to l8.8 after DCT. This decrease by 9.7 points oi) average was signif'icant (p < O.O1).

ge Before l)CT *:p<(}.05

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20

group" was significantly decreased from 2.54 × IO" to 1.61 × IO` (Wilcoxon test, p < O.Ol) (Fig.

3). In the"Not-improved group", the total corint both before and after three months of treatme nt was 2.34 × 10'i, showing no chaf}ge.

The 24-liour physical activity in the

"Impro ved group" and "Not-lmproved group" is shown in Figs. 4 arid 5. In the "Improved group"', physical activity at O-1 o'clock, 2-6

o'clock and 7-8 o'clock was significantly decreased or tended to decrease after three mon£hs eftreatmentcompared with that before DCT. That is the time phase shifted backward by abeut one hour. In the "Not-improved group", physical activity at 5-8 o'clock was significantly

-A.

oM

×

v

-

cr = o

o

4.5 3.0 1.5 Fig. 3 o

rr**--"n){al "Not-iinproved" grotips

'rotal acuvity

(21:OO) nextmommg

" signif'icantly

fl'OM £he"Not-iinproved group

beibre mont}}s

2.34 × lOi, shoNvin(r no cl}an(ye. [lllli Befbre l)CT ee After g inonths of l)CT S. Ko{.lichi Improved physical activi{y in pl}ysical '' m}til the Improved group" 2.54 x le" te l.61 and aftcr g b Not-Improved

tl)e "Improvecl" and

. during the nigh{

' (6:Oe)inthc

decrcased

× IO- (p < ().(}l). In " the total count '

of trea{lnent was b

,,+,,{t: p < o.el

.

increased or tended to increase after three moRths of treatment compared with that before

DCT.

IV Change ill basal rhythm ofEEG

Results of statistical analysis (Wilcoxon test, p value) ef Wave % Time according to frequency baRd "Before DCT first day", "After DCT first day", "Before DCT last day" and "After DCT last day" are showR in Table 1.

In the "lmproved group", a decrease in occip-ital e2, a decrease in central el, and an increase in central and occipital a2 were observed wheit

"After DCrl' firs£ day" was compared with "Before DCT first day". An increase in central ee, an increase in central and occipital ct2 and a decrease ln occipital B2 were observed when

"Before DCT last day" was compared with

"Before DCT first day". An increase iit ceRtral and occipital a2 and a decrease in occipital IB2 were seen wheii "After DCT last day" was com-pared with "Before DCT first day".

In the "Not-improved group", an increase in central 6, an increase in central e2, and a decrease in central and occlpital ct3 were observed when "After DCrT first day" was com-pared with "Before DCT first day". A decrease in central ct2 was observed when "Before DCT last day" was compared with "Before DC"l] first day". An increase in central el a decrease in central

,

a2 and a decrease in occipital a3 were observed

when "After DCT last day" was compaved to

"Befere DCT first day".

The mean, standard deviation, and signifi-cance of dlfference in Wave % Time in central el, al, (x2 and a3,in the "Irr}proved group" aRd "Net-improved group", are shown in Figs. 6 and 7. In the central EEG of the "Improved group", a decrease in el and an increase iri a2 weve observed when "After DCrr fu-st day" was coin-pared with "Before DCT first day". The increase

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za .e > 's O as

-

es o .T-ca

h

x

pt 1200 1000 800 600 400 200 o 4

I)ay Care Treatmentand EEG Analysis

-i- r :

+"

+- ++-:,

tl -I

e-

t1 fv -t

t--l tl

{t .- -t

- -t

* t-t- lt t i- -f --t : -Nt : ; : : : :" 'i l ll

tx

-I "t tl

tl ; li

tl "t l- -t l -l -l ----tt ----

tt--t l

-st . . , - 'x ttt" -- -I -t .

Fig. l'hysical activity in the "ln)proved group"

O 6 l.2 18 24o'clock

A moving average of' g epochs was calculated and activi ty is indica{ed for a 2il・-kour period. "I-lme is shown on the horizontal axis and physical activity on the vertical axis. The broken line indicat¢s the activity level before l)CT ar}d the solid line indicated that aftef 3 months of !)CT. I'hysical activity at O-l o'clock, 2-6 {)'clock and 7-8 o'clock slgniflcantly clecreasecl or tended to decrease after 8 inonths of l)CT con)pared to tl}at before 1)()T.

・・・・・・・・・・・

Befbre l)CT +:p< O.l(}

Af'terg in onths of DCT :i:: p< O.05

21

h

.rt: > 's v os

-

ed U .rr-op

h

£ pt ]. 200 1000 800 600 400 200 o 5 t-,

.:

ts --' -el , .. * -t' * + :-, :,'.,./i:

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:.

"t i l tl ll "- - Jt ts"' ;- ; -t r ',

tl : }-t

ll -- -l : ----lf "l v -l ,. : : t" : : t , .lt x , w" "-1

Fig. l'hysical activity in the "Not-improvecl" group

O 6 12 18 24o'clock

l'hysical activity at 5-8 o'clocl< was signiflcantl>t increased or tended to increase af{er 3 ii}onths ot' 1)CT c()inpared to that l)efore E)CT.

・`・i`"'''''

Befere l)CT ÷:p< O.IO

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22 S. Kouichi

"fable l. Results of stanstical andlysis (p value) of Wdve % Tia}e

6 e2 el a2 a3 62

GENTRAI,

ln}proved

After l)CT fi rst day Before l)CT last day

After DCT last day

M

, T T t t

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t t Not-Improved

After l)CT fiist day Before l)CT last day After 1)CT last day

M

tf

tt

i i ・ ・ ; OCCIi)lTAl. Iinproved Aftei 1)CT {lrst day Before l)CT last day Aftei I)CT last day

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s Not--lmproved After D(]T fl rst day Before l)CT last day Af£er l)CT last day

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i 40 35 30 o ff 25 e1

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el al a2 a3

Wavc % Time ofcei}ti al EEG in t}}e "!mpioved" group A deciease in el and dn increase in ct2 were observed when "Af{¢i i)(IT first day" was compaied with "Before l)CT fits£ day". The inciease in a2 peisis{ed "Befoie l)CT last day" and "Af{ei 1)CT last day".

[II] Befoie l)CT flrst day +:p< O.10

tw Aftei l)CT fi rst day >・:p<O.05

[I]BefoieE)()Tlastday ::p<O.Ol

ew Aftei {)(]T last day

ttt:

p < O.Ol

in a2 continued "Before DCT last day" and

"After DCT last day". In the central EEG of the "Not-irnproved groiip", a decrease in or3 was observed when "After DCT first day" was com-pared with "Before DCT first day". A decyease in a2 "Befere DCT last day", an increase in el and

a decrease observed.

in a2 "After

DCT

last day" We I'e

V Examination based on changes in basal rhythm ef EEG on first day of DCT

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*

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L)ay Cate Tr eatment ai}d EEG Analysis

*

el al a2 a3

Wave % Time of central EEGin the "Not-improved" group A decreabe in ag was observed when "After l)CT flrst day" was com-pared with "Before DCT first day". A decrease in or2 "Before l)CT last day", an ii}crease in O l and a decrease in a2 "After l)CT last day" were observed.

[I] Before DCT fi rst day +: p< O.IO

tw After l)CT f-irst day -;・: p< O.()5 [I] Befo re l)CT Iast day f: s:: p< O.el

ge After l)CT last day

23

to chaRges in EEG on the first day are shown in

Table 2. The or2 band "After DCT first day" mcreased compaied to "Befbre DCT first day"

in l4 patients, l2 of whom were in the

"lmproved group". The a2 band decreased ln 6 patients, only l of whom was in the "Improved gro"p". There was a significant difference between the two groups (Fisher's exact

proba-bility test, p < O.Ol).

The el band "After DCT first day" decreased cempared to that "Before DCT first day" ln l4 patients, 11 of whom were in the "Improved

group". The el band inci'eased in 6 patients, 2 ofwhom were in the "Improved group". An ii}crease in the or2 band and a decrease in the el band were observed in 11 patients; 10 of whom wei'e in the "Irnproved group" and 1 was in the "Not-improved group". Conversely, in 3 patients, a decrease in t}}e a2 band and an increase in the el baRd were observed. All of

"r2ible 2. ()hdnge in

of l)CT

basdl ihythm of EEG on flist day

Basal rhythm of EEG

or2 mcreased a2 decieased

el decreased

el

mcieased el decreased el mcseased Impioved 10 2 l o Not-lmproved 1 1 2 3

these patients were in the "Not-improved

group". There was a significai}t difference between the two groups (Fisher's exact preba-bility test, p < O.05). Six cases showed an increase or decrease in the a2 band and el band; 3 were in the "Improved group" ar}d the other 3 were in the "Not-improved group".

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24

DISCuSSION

I CIinical symptoms

DCrl[" was shown to be clinically effective for troublesome behavior ln the "lmproved group". RegardiRg cognitive function indicated by HDS, there were no changes ir} either the "Improvecl group" or "Not-iiir}proved group" after DCT, although some cases individually showed improvemei}tin tl}is iRdex.

The degree of help reqt}ired as evaluated by ABCD did not change in the "Improved group"

and det"eriorated in the "Not-improved group". Demei}tia is a chrenic disorder' and it is i'eported that DCT was not effbctive in improv-ing cognitive functioni). The results of HDS in this study were in accordance with this view. However, it can not be definitively concluded from this study that DCT is not useful for

improving cogRitive function, since no coinparl-sen was made with patieRts treated at heme for

three menths without receiving DCT. The

degree ofhelp required showed deterioration in the "Not-improved group". Cor}sidering that demer}tia is a chronic progressive disease and deterioration is the natural course, the "Not-improved group" would have been expected to deteriorate without receiving DCT. Conversely, the degree of help required by patients ir} the "Improved group" did not increase. This sug-gests th at DCT prevented an ii}crease in the degree oflrelp required, and the ability to pre-vent this de£erioration is sttggested to be a treat-ment efiflect of DCT.

II Physicalactivity

The activity-log recording (ef physical activi-ty) durlng the r}ight can deterrnine whether good sleep was ebtained. DCT hardly influ-enced the number of total counts of physical activity in the daytime; however, a slgr}ificant

S. Kouichi

decrease in ceunts at night was fotmd in the "Impi'oved group". This suggests that DCT was effective in impyoving dementia-induced trou-blesome behavior such as agitation and war}der-ing at nighttime.

In general, troublesome behavior in elderly

persons with demeRtia living at home is

increased in the afternoon or the eveniRg to r}ighttime compared with that in the morning. Pvloreover, the attendant person at home is usu-ally the daughter-ln-law who is busy with house-work during the morning and has diliflculty in fir}diRg time to be with the patient when the patient is less active. Thus, the patients are left alone and remain inactive. Most of the patients in this study had previously worked as fariners during the daytime, although some had worked in other occupations when they were younger. With regard to the rhythm of day and night,, DC'I] was considered to have increased the phys-ical activity of patients in the morning aRcl decreased the activity from midnight to early in

the momiRg in the "lmproved group". More-over, the time phase shifted backward by about one hour with DCT. These results show that the rhythm of day and night reti.}rned to that

previ-ously acquired as a whole. If dernentia is defined as "decrease in cognitive ftmction due to chronic orgar}ic brain disorder, making inde-pendent life diMcult", it can be said that the patient's life patterR following DCrlr becomes closer to that before the onset of deraentia. Moreover, the authors14) reported that when bifeii}elane hydrochloride (a rnetabolisi/ri-enhai}cing agent) was administered fbr eight weeks to elderly persoRs with dementia showing motivational loss after cerebrovascular disor-ders, physical activity showed a similar char}ge iii the rhytl}m of day and night. This suggests that DCT achleved the same effects as drugs. In this study, seaseRal changes including the

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num--l)ay ()are Treatment and EEG Analysis

ber of daylight hours were not considered. How-ever, the infiuence of such exterHal factors should be examined in the future.

IIIBAsAi. RliyrHM oF EEG

First of all, EEG obtair}ed "Before DCT first day" and "After DCT flrst day" were examined. Detailed exarr}ination of the chakges in basal rhythm of EEG in the "Improved group" and "Not-improved group" identified changes in the "Improved group": a decrease in Wave % Time

in occipital e2 and central el, and aR increase in central and occipital a2 were also identified.

In the "Not-improved group", an increase in Wave % "I"ime iR central 6, an increase in cen-tral 6}2, and a decrease in cencen-tral and occipital ct3 were also ideritified. Six hours of DCT per day is regarded as a stimulant. Or} the first day

of DCT, changes in the basal rhythm of EEG

were already observed, so iti can be ii}terpreted t}}a{ some response to stimulation was obtained. Examination ofcerebiJal blood flow etc. is

need-ed to determine the mechanism causing these changes. This was considered to be a change

that exceeded the so-called diurnal variation in

EEG.

Next, EEG changes after three months of DCT were examined. Here, the results of EEG performed at the same time of day as "Before DCT first day" arid "Before DCrl" last day" were

examined. The most characteristic change

observed was a chai}ge iR tl}e a2 band. Increas-es in the frequenciIncreas-es ef central and occipital EEG were observed in the "Improved grotip", while a decrease in the frequer}cy of central EEG was observed ln the "Not-improved group". Changes in average values (summarized in the figi}res and tables) showed a decrease in the lowey frequency altd an increase in the higher frequency with a boiu}dary at the al band in

25

the "Improved group", and an increase ir} the lower frequency and a decrease in the higher frequency in the "Not-improved group". In general, a decrease in the a band and an increase in 6and e bands are recogRized in

elderly persons with deinentiai5-i9). Usui et al 2('>

reported that adrninistration of a metabolism-enhancing agent over a long period resulted in

a decrease in the slow band wave and an

ii}crease in the fast band wave with a boundary at the a2 band. Moreover, Ishizuka et at2i) reported similay resvlts following administra-tion of a cerebral vasodilator. In tl)is study, a

decrease in the slower band wave and an

increase in the faster band wave were noted after DCT. The boundary was at the al band, which is approximately 1.0 Hz lower than the a2 baRcl. This restdtshows the same teRdeRcy as the effect of rnedical treatment. These results

suggest that DCT may induce some favorable

changes in brain function. It is easy to regard DCT as a stimulant for elderly persons with dementia living at home who have little contact with society. It is speculated that these EEG changes appear as a result of changes in brain function of patients after receivii}g repeated stimulation for 6 hours a day during three moRths of DCT.

IV ChangeslnEEGonfirstdayofDCT

DCT for elderly persons with dementia is labor intensive and is not effective for all

patients. rlb use DCT eflf'ectively, it is r}ecessary te select patients who would optimally ber}eflt from DCT. Whether the change in clinical man-ifestatier}s after DCT can be estimated from the EEG changes on the first day of DCT was exam-ined. The a2 band in the basal rhythm of EEG was increased in 14 patients, 12 of whom were in the "lmproved group". An increase in the or2

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26

observed in l1 patients, 10 of whom were in the "Improved group". Conversely, all S patients who showed a decrease ln the a2 baRd and an increasein the el band were ii} the

"Not-improved group". There was a significant diffbr-ence in these changes. The i'esults will become clearer by increasing the number of patients tested, by further examining patients who could not complete three months of DCT due to hos-pitalization or admissioR to facilities for the elderly, and by examining data includiRg EEG bands other than or2 and el.

From the above results, patients who show an increase iR the a2 band aRd a decrease in the el band may be expected to show aR improve-mer}tin clinical symptoms with DCT Therefore, DCT was coRsidered positive for these patients. Conversely, patients who showed a decrease ln the oc2 band and aR iRcrease iR the el band may notobtain ber}efit from DCT alone aBd therefore other treatmeRts need to be coRsid-ered. Thtis, it was confirmed that the quantita-tive anaiysis of basal rhythm of EEG on the first day of DCT is aB important index for predictlng the clinical course after three months of treat-ment.

V Methodologicallimi£ations

The number of cases iR this study was small because of the loRg follow-up peried. However, the effbct of DCT was great enough to produce a cllRically and statistically significant

improve-inentin troublesome behavior. Most of the

patients in {,his study had previously worked as

farmers although some had worked in other occupations. Therefore, they were not a ran--dem sainple of the population. Thus the results ofthis study may Rot apply to all demented peo-ple in all classes. There are differences in the daily schedules of DCT among lnstitiitions, but our schedtile is thoiight to be one of the most

S. Koulchi

orthodox. The criteria for classificatiof} of "Improved grotip" and "Not-improved gro"p"

are not universal at presei}t. Evalt}ation of DCT for a three month period is also not tmiversally acknowledged.

CONCI.USION

Improvement in clinical symptoms was

obtained when elderly persoits wi£h dementia were treated with DCT. This was examined in detail using psychophysiological iRdexes such as physical activity aRd EEG. From the analysis ef physical activity before and after DCT, 65 % of patients in whom the treatment effect of DCT was confirmed showed recovery of circadian rhythm. From quaRtitative EEG ar}alyses ln

improved subjects, a decrease in the lower fre-quency and aR increase in the higher frefre-quency with a botmdary at the al band were observed. To further study this mechaRism, changes iR cerebral blood fiow etc. should be examined in the ftiture. At present, favorable changes iR the patient's brain fuBctioR and improvemeR£ of clinical symptoms were obtained with DCT. The quantitative analysis of basal rhythm of EEG on the first day of DCT was concluded to be gsefu1 for identifying patients who would optimally obtain beRefit from DCT.

ACKNOWI.El)GMENTS

The auther is grateful to Pref. Tetsuhiko Kariya for his vakiable comments oR the manu-script, The author also thanks Associate Pro£ Hitoshi Fukuzawa, Assistant Pro£ Ybsl}ikazu

Ishizuka Lecturer Akira Usui and Dr.

'

Masamichi Mochizuki (Director of Kyousai Hos-pital) for advice and encouragement.

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i)ay Care Treatmei}tand EEG Analysis 27

IllZFERENCES

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Kitajima E. et at.: l)evelopment of a Troublesome Behavior Scale (TBS) fbr Elderly l'a£ients with 1)emei}tia.Japai}eseJot}rnal of l'ublic Health 41:

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