Timeline with significant events, interventions and outcomes
| Month/ year | Significant history, presentation and observation details | Interventions | Significant outcomes |
| 2015 | Diagnosed with Alzheimer’s disease and associated depression. Symptoms of impaired cognition in addition to hallucinations. Medical history of hypertension. No pre-existing psychiatric history or family history of dementia. Ex-smoker and teetotal. | Memantine, risperidone and mirtazapine had been prescribed by the local memory clinic. | None for our programmes |
| Sept–Nov 2019 | Initial person-centred, goal-oriented assessment performed in-person in the man’s home. Staging scores indicated moderate to moderately severe stage of dementia. Significant difference in patient and proxy quality of life scores noted. | Sept 2019: non-pharmacological intervention dementia therapy programme initiated three times a week. Oct 2019: attendance at community group dementia therapeutic activity programme sessions and a day centre commenced; one-to-one sessions two times a week. | Proxy quality of life score improved from 19 to 35 after 1 month. Activities of daily living remained stable. Neuropsychiatric Inventory Distress score increased due to increase in hallucinations, agitation. |
| Dec 2019 | One-month interruption of programme due to annual seasonal holidays and a temporary change in care arrangements. | No interventions for 1 month. | No assessments. |
| Jan 2020 | Deterioration in cognition and global functioning and increased apathy observed. Fewer hallucinations reported. Increased dependence for assistance noted. | One-to-one and group sessions re-initiated. Therapy focused on his interests in arithmetic and multilingual abilities as a speaker of 5 languages. | Deterioration in early January MMSE score noted in orientation to time and place, mental arithmetic, naming ability and short-term memory. GDS and FAST scores indicated deterioration in global functioning and cognition. NPI scores improved due to fewer hallucinations and associated agitation. |
| Feb 2020 | There was a significant qualitative improvement in his conversational ability compared with the early January sessions. In addition, numeracy and language skills, including reading and writing, were observed to improve in the cognitive stimulation activities. | Continued in-person programme. | MMSE improved on orientation time and place and mental arithmetic. GDS/FAST remained unchanged but Barthel’s improved. |
| End Mar 2020 | UK goes into lockdown due to the COVID-19 pandemic. | Cessation of in-person programme and initiation of digitally delivered therapeutic activity programme online. | No further formal assessment due to lack of tools validated for online use. |
| Apr–May 2020 | After the period of isolation, qualitative observation noted worsening of cognition observed in deterioration of language skills and speech production; there were two episodes of wandering and getting lost which had not occurred before. Worsening nocturnal restlessness resulted in poor sleeping patterns. Non-elective hospital admission for pneumonia. | Two times weekly 30-minute interactive online therapy sessions continued except during hospital admission. | Qualitative verbal feedback and visual observation in video sessions noted signs of improved mood post-session with more laughter, smiling and interaction with the therapist and carer. |
| Jun–July 2020 | Increased distractibility; reduced attention and concentration; disinterest in usual activities such as watching sport on television; decline in comprehension; deterioration in language abilities with reversion to languages spoken in earlier life and fatigue observed especially after physical activity. Increased distress due to hallucinations noted to be more frequent during the period of reduced physical and social activity. Occasional episodes of incontinence started to occur. | Online session frequency was increased from 2 to 3 times a week in response to noted attention and language deterioration and cognitive stimulating activities were increased in intensity. Returned to some socialisation with family following cessation of lockdown. | An associated improvement in attention and concentration to session activities noted after increasing online session frequency. The accumulative effect of repeated sessions, for example, with mental arithmetic challenges, was evident by improvement in responsiveness and quicker task completion. Improved engagement during session activities was noted by increased alertness, reduced apathy and observed positive emotions (smiling and laughter) with his wife noting “that was the first time he smiled all day.” |
| August 2020 | Returned to day centre second half of August. | Attendance at the day centre resumed 3 times a week. | It was noted that within 2 weeks of returning to the day centre, the man’s comprehension of spoken word and interactions during the online session seemed to have improved. |
| September–November 2020 | Independent attempts at physical exercise within the flat were noted by his wife. Some objective symptoms of dementia progression continued including reduced attention, occasional episodes of incontinence, increased apathy outside of sessions. | Continued 2 online therapeutic activity sessions a week and attended the day centre for 3 days a week. | Ongoing stimulating activities were noted to be associated with reduced apathy and increased signs of positive emotions within the sessions. Plans to return to in-person sessions were still pending at the end of November 2020 due to continued COVID-19 restrictions. |
FAST, Functional Assessment Staging; GDS, Global Deterioration Scale; MMSE, Mini-Mental State Examination; NPI, Neuropsychiatric Inventory.