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Psychosocial Interventions For Dementia: From Evidence To Practice
Psychosocial Interventions For Dementia: From Evidence To Practice
011957
340
Psychosocial interventions for dementia
Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957 341
Patel et al
years that there have been more rigorous studies improved night-time sleep, increased daytime
of its use with people with dementia. It is usually wakefulness and reduced agitated behaviour in
delivered in groups by a trained music therapist, the evening.
and it makes use of the expressive elements of Figueiro (2008) proposes a 24-hour lighting
music (such as rhythm, melody and tone) to relate scheme that can positively affect sleep, mood and
between the therapist and patients. Previous agitation as well as reduce the risk of falls.
musical skills are not required to be able to engage
in this therapy. Ueda et al (2013) reviewed the Aromatherapy
literature on the topic and concluded that music Aromatherapy is a complementary therapy that
therapy had moderate effects on anxiety and involves the use of essential oils (mainly Melissa
smaller effects on behavioural symptoms; thus, balm and lavender) applied directly to the skin,
they felt that there is evidence that this therapy is heated in a burner or placed in a bath. It is thought
effective for BPSD. to work mainly by providing sensory stimulation
and the variety of application methods means it
Sensory interventions can be used in different settings. Fung et al (2012)
Light therapy concluded that their review of 11 randomised
Light therapy has shown mixed but promising controlled studies showed evidence in favour
results. The physiology of our internal biological of the use of aromatherapy for BPSD as well as
clock responsible for our sleep/wake cycle improvement in cognition and quality of life, but
is complex. This internal biological clock is also noted reports of adverse effects.
situated in the suprachiasmatic nuclei of the
hypothalamus. Although it is sensitive to social Multisensory approaches
activities and meal times for its regulation, its Rooms specifically designed to achieve ‘sensori
strongest regulator is the light/dark cycle (Hanford stasis’ are thought to reduce agitated behaviours.
2013). It is known that with the progression of Sensoristasis, which has been in use since the
neurodegenerative dementias, sleep is disrupted; 1970s, is a balance between being over- and
therefore maintaining the sleep/wake cycle is a under-stimulated (Sanchez 2013). A specialised
biologically plausible intervention. The variation multisensory room may contain items such as
in the intensity of light used across studies as coloured lights, water columns and aromatherapy.
well as the timing were critical to the outcomes Sanchez et al (2013) carried out a review
observed (Dowling 2005), and likely account for to determine the efficacy of this approach in
the differences in study results. dementia. They reviewed papers from 1990 to
A Cochrane review of eight trials (Forbes 2009) 2012 and although 63 studies were found, only
revealed that there was inadequate evidence of 18 fulfilled their inclusion criteria. They looked at
the effectiveness of light therapy in managing the outcomes of behaviour, mood, cognitive level
cognition, sleep, function, behaviour or psychiatric and communication/interaction. With respect
disturbances associated with dementia, and that to behaviour there are conflicting results; some
further studies of high methodological quality and studies show a decrease in agitation, some find no
further research are required. It is important to significant difference. Interestingly, one study in
note that the review authors defined light therapy which multisensory approaches were integrated
as ‘any intensity and duration’. In fact, a study into daily care showed that improvements in
by Barrick et al (2010) showed that agitation certain aspects of behaviour, such as apathy and
was actually higher under high-intensity bright aggression, were maintained 15 months after the
morning light. new regime had been introduced. Integration of the
Burns et al (2007) showed that after 2 weeks of approach into the daily care routine also showed a
light therapy at 10 000 lux from 10.00 h to 12.00 h significant improvement in mood. It seems that the
there were improvements in the Cohen-Mansfield use of multisensory approaches in early dementia
Agitation Inventory (CMAI; Cohen-Mansfield improves scores on the Mini-Mental State
1986), and it is suggested that individuals with Examination (MMSE; Folstein 1975), although
higher initial CMAI scores may benefit the most the outcome of cognition has not been studied
from light therapy. More recently, Hanford & extensively. On the outcome of verbal and non-
Figuero (2013) published a review of 17 studies verbal communication it seems that the integrated
on the effects of light therapy on sleep, agitation approach produced significant improvements. The
and mood. Regarding sleep, the authors found that long-term effectiveness of these approaches needs
exposure to bright light at >1000 lux at the cornea to be studied in further trials.
342 Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957
Psychosocial interventions for dementia
Psychological interventions
Activity-based interventions
Doll therapy
Exercise
James et al (2006) and Verity (2006) have provided
Physical exercise features prominently in terms
demonstrable efficacy for the use of dolls as
of primary prevention of dementia in reducing
therapy for people with dementia. Although not
vascular risk. Exercise appears to have a neuro
well understood in terms of theoretical base, it
protective function, increasing hippocampal
has grown from the work of Bowlby and attach
volume, although the direct effect on cognition is
ment theory (Bowlby 1960) and links the way
still unclear; there are obvious benefits for quality
people with dementia experience the world (as
of life, physical health and affective symptoms.
unfamiliar and unsafe) to heightening their need
Forbes et al (2008) state that there is more
for attachment (frequently attaching themselves to
conclusive evidence regarding aerobic exercise,
staff members, other residents or objects) (Box 3).
with National Institute for Health and Care
Meissen’s (1993) work has also been integrated to
Excellence (NICE) guidance (National Institute
produce a rationale for the use of dolls as therapy.
for Health and Clinical Excellence 2008)
It was the Newcastle Challenging Behaviour
recommending 30 min of aerobic exercise five
Service that delivered the first empirical studies of
times a week. Extrapolation from studies with
healthy older people and animals is difficult
owing to methodological issues, but the potential BOX 3 Case study 2: doll therapy
of physical exercise to ameliorate the symptoms of
dementia is interesting. Mr A was a resident in a nursing home, having a doll, yet he chose it himself and
Buchman and colleagues (2012) concluded with dementia and complex needs as was reassured by the connection he formed.
that higher levels of daily activity are associated well as loss of communication skills. As
In this case the unsettled and agitated
with a reduced rate of Alzheimer’s disease, and a result he was becoming very distressed
behaviour can be an expression of unmet
Winchester et al (2012) found that for a group of and for long periods would pace up and
psychological need. Kitwood (1997) states
down the corridors, getting involved in
people with early Alzheimer’s disease, walking for that these unmet needs are often the need
angry exchanges with other people. One
over 2 h a week for 1 year led to a significant increase for attachment, comfort, inclusion, love,
of the other people in the home was using
in MMSE score over the control group. Studies identity and occupation. Mr A’s unsettled
a doll and finding comfort in doing so.
have demonstrated improved cognitive functions, behaviour might have a result of any of
Unexpectedly, one day Mr A found the doll
executive function (Baker 2010), attention and these needs being unmet. Doll therapy is an
and started to walk around the home with
attempt to meet these needs.
information processing (Lautenschlager 2008; it, talking to and cradling it. He appeared to
Vreugdenhil 2012) and improved physical health find great comfort in the doll and it became As it is difficult to assess how people
(Heyn 2004). his constant companion. One evening staff will respond to dolls, there are guidelines
found him sleeping on the edge of his (James 2006) about their use which
Other activity-based approaches bed where he had made a cradle from his should always be considered before
blankets for the doll. The doll met some implementation. The doll should be available
Occupation is described by Kitwood (1997) as one need within him that was not satisfied for the person to engage with themselves
of the main psychological needs of people with by other interventions or by prescribed rather than given to the person when they
dementia and by Perrin (1997) as the severest loss pharmacological agents: he was relaxed, do not react well. In addition, if doll therapy
in dementia. Lack of occupation leads to sensory showed pleasure and his periods of distress is identified as a possible intervention, its
deprivation, boredom, isolation and low mood abated. It was not anticipated by any of the purpose should always be explained to the
(Brechin 2013). Activity covers a diverse range of staff that this man would even contemplate family first.
interventions, and studies have looked at particular
Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957 343
Patel et al
344 Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957
Psychosocial interventions for dementia
Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957 345
Patel et al
follow-ups. The meta-analysis does not answer studies, showed that educational and support
questions about the optimal duration, frequency programmes for caregivers reduced caregiver
and setting of interventions at a practical level. burden when compared with standard care.
These will be defined questions for future research.
Environmental interventions
Post-diagnostic support Lawton (1990) recognised the role of the environ
The National Dementia Strategy (Department of ment, acknowledging the vital nature of designing
Health 2009) identifies the need for good-quality, environments to meet the needs of people with
structured support after diagnosis. There are dementia, but describing the challenges in terms
various models of post-diagnostic support for of robust research design to measure efficacy
carers, but most are psychoeducational in nature, and impact on quality of life. Zeisel et al (2003)
providing support for 6–8 sessions. Research by demonstrated an association between behaviour
Whitlatch and colleagues (2005) demonstrate that and environmental design features, describing the
people in the early stages of dementia are often as potential the environment has for contributing
aware of the practical implications and problems to improvements in the symptoms of dementia
as caregivers. Robinson et al (2005) suggest by being comforting, safe and understandable.
that a support group for the person and their The physical environment can help people with
potential carer may provide the greatest benefit dementia achieve their potential, avoid increased
for both parties. disability and enrich life quality (Davis 2009).
A systematic review by Marim and colleagues Although the physical environment is important,
(2013), including seven randomised clinical so too is the psychosocial environment, preserving
personhood, reducing the need for antipsychotic
medication and improving quality of life
BOX 7 Measuring outcomes in psychosocial interventions research: (Werezak 2003).
the hurdles
The principles of dementia-friendly environ
Psychosocial interventions do not lend Sample size and study duration ments are now widely recognised. Bicket and
themselves well to the gold standard Very few studies in Schwarzbach et al ‘s
colleagues (2010) indicated that the physical
randomised controlled efficacy trials used review had more than 200 patients; the environment in assisted-living facilities probably
for pharmacological interventions. In duration of studies ranged from 1 h to 52 affects neuropsychiatric symptoms and quality
addition to reviewing the findings from two weeks (they do not report an average). of life. Parker et al (2004) recommend that there
health technology assessments on should be a balance between choice and control,
non-pharmacological interventions for Comparators
physical support, normalness and authenticity,
dementia in Germany (German Institute for Many studies do not define ‘standard care’, comfort, cognitive support and personalisation as
Quality and Efficacy in Health Care 2009; which will be different across studies.
these are all associated with increased quality of
Rieckmann 2009), Schwarzbach et al (2012) Furthermore, staff’s awareness that a study
life. Privacy reduces aggression and agitation and
provide an insightful and extremely clear is being carried out may mean that patients
analysis of the methodological problems improves sleep (Morgan 2004).
in the standard care arm receive a change
encountered by research into non- in their usual care as staff increase their
pharmacological interventions, as well as engagement with them. Measuring outcomes of psychosocial
providing some suggestions for ongoing Even if there is a good degree of matching interventions
research. for patients taking medication, one might A commentary by Kolanowski & Hill (2013) on
Inclusion criteria argue that it may reduce the patient’s the Brodaty et al meta-analysis raises worthwhile
ability to derive benefit from psychosocial points. Kolanowski & Hill report that the
Studies use different tools to make a
interventions or that it may be harder for meta-analysis followed the PRISMA (Preferred
diagnosis – how comparable then are the
a psychosocial intervention to show an Reporting Items for Systematic Reviews and
studies?
additional benefit.
Meta-Analysis) statement guidelines (with a few
Interventions themselves
Clinical end-points (outcomes) exceptions), increasing confidence in the validity
Interventions with the same name may,
In pharmacological research clinical end- of their results. These guidelines help authors
in practice, be applied very differently, so
points are requested by drug authorisation improve the quality of their reporting for studies
treatments even with the same name cannot
always be compared. Some treatments may agencies. In non-pharmacological research, of this type. Kolanowski & Hill feel that current
have been applied as a major departure there is currently little guidance and studies measures of BPSD lack precision, meaning that
from the usual delivery of care; others with may be using non-validated questionnaires, they might not pick up on a change in outcome.
the same name may have been used for only leading to problems in interpretation of the They also reiterate that quality-of-life indicators
a set number of sessions. Again, comparison outcomes the produce. may be better measures and this appears to be an
is not ideal, but does occur in practice, Schwarzbach et al remind us that the lack of emerging theme that we have noted. Kolanowski
obscuring true results. evidence should not imply lack of efficacy. & Hill also report that reliance on randomised
controlled trials as the sole source of evidence
346 Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957
Psychosocial interventions for dementia
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MCQs 3 Which of these statements regarding d Forbes et al looked at light therapy of various
Select the single best option for each question stem post-diagnostic support is false? intensities and timings
a research supports a structured approach to e Burns et al showed that light therapy for 2
1 Doll therapy:
post-diagnostic support weeks at 10 000 lux from 14.00 h to 16.00 h
a is based on Piaget’s developmental theory
b Whitlatch et al found that people in the early reduced agitation on the CMAI.
b is a gender-specific intervention
c can reduce anxiety and increase activity levels stages of dementia are often unaware of the
d is a harmless approach that can be used with diagnosis 5 Regarding non-pharmacological
everyone c Robinson et al felt that support should be interventions:
e is not an effective alternative to medication. provided for the carer and the person with a they should be tried if medication is
dementia together unsuccessful
d supporting carers at the start can prevent b they are not effective as the evidence base is
2 Regarding reminiscence therapy and life
crises occurring weak
story work:
a the REMCARE trial showed modest benefits for e the National Dementia Strategy states that c cognitive stimulation therapy is a useful
most patients everyone should have post-diagnostic support. intervention for everyone with dementia
b the REMCARE trial was neither positive or d they are a cheaper alternative to medication
negative for caregivers 4 With regard to light therapy: e they should be about the general well-being of
c the REMCARE trial was a cohort-based study a studies suggest that the timing and intensity of the person rather than just minimising BPSD.
d life story work is based partly on the principles the light therapy are crucial to its efficacy
of reminiscence therapy b the internal biological clock is least sensitive
e McKeown et al ’s 2006 randomised controlled to light
trial concluded there were ‘far reaching’ c Barrick et al showed that agitation was lower
benefits. under high-intensity morning light therapy
Advances in psychiatric treatment (2014), vol. 20, 340–349 doi: 10.1192/apt.bp.113.011957 349
Psychosocial interventions for dementia: from evidence to
practice
Bhamini Patel, Mark Perera, Jill Pendleton, Anna Richman and Biswadeep Majumdar
APT 2014, 20:340-349.
Access the most recent version at DOI: 10.1192/apt.bp.113.011957
References This article cites 61 articles, 3 of which you can access for free at:
http://apt.rcpsych.org/content/20/5/340#BIBL
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