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Tuesday, May 17, 2022

‘Social prescriptions’ offer new and exciting non-pharmaceutical dementia treatment

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With no cure, dementia researchers and clinicians alike are constantly on the hunt for new and innovative approaches to symptom management and reducing, where possible, rate of disease progression.

Whilst memory loss is perhaps the most commonly thought of symptom, the degenerative disease can cause a host of other distressing symptoms, such as depression, anxiety, agitation, sleep disturbance, aggressive behaviour and psychosis (delusions and hallucinations).

Pharmaceutical interventions are a long standing approach to managing these, but many come with side effects.  

But a new approach, “social prescribing” has been showing some promise, and has been the basis for a project created by Bigger Hearts Dementia Alliance Ballarat called Green Scripts.

The project aims to harness the power of nature to impart a positive benefit on the health outcomes of those living with dementia.

The centrepiece for the project is the Dementia Sensory and Forest Trail located in the Woowookarung Regional Park in Ballarat.

The trail has been specifically constructed to suit the needs of those living with dementia, offering the chance to move, think and feel, as well as connect with loved ones along the way.

There are two sections to the trail, one specially catered for those in wheelchairs or with limited mobility.

Resting points along the way are closely spaced, providing a safe, inclusive, sensory experience.

A map of the ‘Welcome, Wander’ trail at the Dementia Sensory and Forest Trail, which is dementia-friendly and accessible for those with disability.

According to Dr Mark Yates, geriatrician and associate professor in Aged Care, Rehabilitation & Palliative Care at Deakin University’s Ballarat Clinical School, the initiative is an exciting advancement for the medical community.

“A tablet will do something for one thing; you prescribe this and you’re engaging with multiple parts of the human spirit,” he says.

“Engagement with community and social connection is as important, and sometimes more effective, than actual pharmacology or surgery.

“That relates to the things we know about dementia.

“We know for instance, that lack of social connection is associated with worsening cognitive performance… and we also know that cognitive engagement – doing something that’s new or different – improves cognitive performance.”

Associate Professor Mark Yates commends the Green Scripts trial, which he says not only holds promise as a treatment for the symptoms of dementia, but engages the human spirit in a way not possible via standard pharmaceutical approaches.

Yates notes that social prescriptions such as Green Scripts would be most beneficial at the stage of mild cognitive impairment.

“…which is a condition where there’s a change in memory and thinking, albeit subtle, but it doesn’t interfere with day to day functions. Of that population about 16 per cent will go on to develop a dementia each year, so only a small number.

“If that population is encouraged to lose weight and take exercise, socially and cognitively engage, then, in fact, we think that there is an ability to reduce the likelihood of progression.”

As opposed to the chastising experience felt by patients who are told to stop a number of noxious habits, social prescriptions are a positive addition to doctors’ available recommendations.

[If those at the dementia stage of mild cognitive impairment are] encouraged to lose weight and take exercise, socially and cognitively engage then, in fact, we think that there is an ability to reduce the likelihood of progression.

Dr Mark Yates, Deakin University

“Saying that someone’s script is ‘well, lose weight’: it’s not really helpful to a person,” Yates says.

“But if, in fact, you say, ‘why don’t you take a walk in the Woowookarung Regional Park, that’s much more of a positive, direct piece of information.”  

And whilst community based initiatives can take charge of encouraging such activities, Yates notes that a doctor’s endorsement carries weight.

“When doctors provide advice, it has a very significant effect. We know that there’s a placebo effect that’s strong and there’s a higher likelihood of adherence than if it’s advice coming from others.”

Although it is difficult to present such recommendations alongside medical interventions developed in the lab, backed by years of trial data, curiously, not all common prescriptions meet the empirical gold standard.  

“Those over the age of 65 represent about 15 per cent of the population but consume 33 per cent of all the pharmacotherapy,” Yates explains.

“And yet of all the meta-analysis, only about 2-3 per cent of all meta-analyses on the pharmacotherapy that I’m using is done in the population over the age of 65. 

“So if you actually believe, as a geriatrician, you’re only working with a pure evidence-base… you’re misguided.

“The next step to say, ‘well, I haven’t got as much hard evidence that there’s going to be real benefit, but the truth of it is, at least I’m going to do no harm. And that’s the first rule in the Hippocratic Oath.”

With this in mind, alongside the conclusion there is still “a lot of art in medicine”, Yates sees a place for such innovative approaches, especially where they may serve to strengthen clinicians’ artillery of preventative interventions.

“What we’ve got has a degree of evidence, built around a disease and illness base, not wellness. So if someone doesn’t have a disease, but is at risk of acquiring it, we seem to have very little in the way of preventative strategies.

“We’ve got a few where you throw tablets at people, which is why we give people cholesterol lowering drugs and aspirin… [but] that requires huge amounts of study to demonstrate efficacy…

“Why not bring in some of the green scripts or the social scripts, which can have similar sorts of benefits – different mechanisms, but without any of the side effects.”

Green Scripts get tick of approval from Dementia Australia

Dr Kaele Stokes, Dementia Australia’s advocacy and research executive director, tells Aged Care News that the Bigger Hearts’ initiative is a prime example of the benefits that come from developing ‘dementia friendly communities’.

“In the instance of this particular project, they’re focusing on making sure that there is a more consistent approach to social prescribing, where people living with dementia are connected through meaningful activities and opportunities in their local community and that is being facilitated through their GP.

Dr Kaele Stokes, Dementia Australia’s advocacy and research executive director, says social prescribing can apply to a range of social activities, not just outdoor, nature based interventions.

“This is really important because one of the consistent touch points of a person, throughout their life, is their GP – so it’s great to see that the Ballarat Bigger Hearts Alliance is looking at how they can build that sense of community through their green scripts.”

She notes, however, that social prescribing can apply to a range of social activities, not just outdoor, nature based interventions.

“Lots of other dementia friendly communities are approaching it completely differently, so they might be more focused on improving access to particular social programs; they might look at how to make the local cafe more dementia friendly…”

Stokes emphasises that so long as the fundamental tenants of social and cognitive engagement are satisfied, social prescriptions can be developed in bespoke, individualised manner.

“So there’s not really a cookie cutter model of what dementia friendly communities look like. It could be lots of different things depending on what’s going to be most important to that local community.”

Dementia Australia is the national advocacy body for the 487,500 Australians living with dementia and the almost 1.6 million Australians involved in their care.

In a paper released in November 2021, Dementia Australia revealed that, despite the counter-productive effects of isolation on disease progression, 74 per cent of persons living with dementia surveyed said people have not kept in touch as they did prior to their dementia diagnosis and 80 per cent had not been invited to social functions.

Their award-winning Dementia-Friendly Communities program was created in response to this phenomenon, encouraging communities and organisations across the country to develop initiatives to enable the greater integration of those living with dementia into the community and to end the damaging stigma surrounding the condition.

To find out more about Dementia Australia’s work, follow this link.

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