Acupuncture - National Council of Certified Dementia ...
Leeds Institute of
Health Sciences
FACULTY OF MEDICINE AND HEALTH
A Systematic Review of Non-Drug Treatments for Dementia
Claire Hulme
Judy Wright
Tom Crocker
Yemi Oluboyede
Allan House
July 2008
CONTENTS
Page
EXECUTIVE SUMMARY 4
ACKNOWLEDGEMENT 11
SECTION ONE 12
Background 12
Aim 15
Methodology 16
Literature Search 16
Quality Appraisal 18
Dementia Organisation 19
SECTION TWO 20
Review of Effectiveness 20
Interventions 20
Symptoms 21
Interventions and Symptoms 22
Overview of Papers 23
Interventions 23
Acupuncture 23
Animal Assisted Therapy 24
Aromatherapy 27
Behaviour Management 29
Cognitive Stimulation Therapy/Cognitive Training 31
Counselling 35
Environmental Manipulation 35
Light Therapy 37
Massage/Touch 39
Music / Music Therapy 41
Physical Activity/Exercise 47
Reality Orientation 50
Reminiscence Therapy 51
Snoezelen/Multi-sensory Stimulation 53
TENS 57
Validation Therapy 58
SECTION THREE 61
Introduction 61
Interventions 62
Acupuncture 62
Animal Assisted Therapy 63
Aromatherapy and Massage 65
Behaviour Management 70
Cognitive Stimulation Therapy/Cognitive Training 71
Counselling 72
Environmental Manipulation (including lighting) 72
Music / Music Therapy 76
Physical Activity/Exercise 79
Reality Orientation 83
Reminiscence Therapy 84
Snoezelen/Multi-sensory Stimulation 85
TENS 86
Validation Therapy 87
Symptoms or Behaviour 89
Creating a Relaxing Environment 90
Activities 92
Aggression 95
Agitation or Anxiety 97
Depression 100
Hallucinations 103
Sleeplessness 105
Wandering 106
SECTION FOUR 108
Conclusion and Implications for Carers 108
Implications for Future Research 111
Implications for Service providers and Commissioners 113
REFERENCES
References (studies/papers included in review) 157
References (report references) 160
APPENDIX ONE (search strategies) 164
APPENDIX TWO (data extraction template) 171
TABLES, MATRICES, BOXES
Table 1: Acupuncture 116
Table 2: Animal Assisted Therapy 117
Table 3: Aromatherapy 119
Table 4: Behaviour Management 121
Table 5: Cognitive Stimulation Therapy/Cognitive Training 123
Table 6: Counselling 126
Table 7: Environmental Manipulation 127
Table 8: Light Therapy 129
Table 9: Massage/Touch 132
Table 10: Music /Music Therapy 134
Table 11: Physical Activity/Exercise 140
Table 12: Reality Orientation 144
Table 13: Reminiscence Therapy 145
Table 14: Snoezelen/Multi-sensory Stimulation 147
Table 15: TENS 150
Table 16: Validation Therapy 151
Table 17: Systematic reviews that did not identify 153
any studies for inclusion
Matrix 1: Interventions and Symptoms Evidence Assessment 114
Matrix 2: Interventions, Behaviour/Symptoms, Oganisation 154
Box 1: Reasons for Exclusion from the Review 18
Box 2: Types of Symptoms 21
Box 3: Interventions and Symptoms 22
EXECUTIVE SUMMARY
In the UK there is increasing focus on dementia. A recent report from the House of Commons Committee of Public Accounts acknowledged that dementia, despite its financial and human impact, has not received the same priority status as other diseases[1]. The report goes on to highlight the heavy burden carried by those caring for relatives with dementia at home. Indeed these informal carers deliver most of the care to people with dementia in the UK and many are elderly and frail themselves[2].
Aim
The aim of this report is to help informal carers who want ideas about non-drug approaches for dementia, that they might try or that they could try to access.
Using a two part process, initially a systematic review was carried out in order to addresses the following questions:
• What non-drug treatments work and what do they work for?
• What non-drug treatments might work and what for?
• What non-drug treatments do not work?
The second part of the process searched the websites of four national (UK, USA and Australia) and international (Europe) dementia organisations to identify recommendations or suggestions for non-drug approaches for dementia. In each case the strategies identified from the websites were aligned with the non-drug treatments identified in the systematic review to produce a series of suggestions or ideas for informal carers about non-drug approaches for dementia, that they might try or access.
Methodology
Seven electronic databases were searched for systematic reviews published since 2001. Screening of retrieved papers was two staged. Titles and abstracts were first screened. The full papers of those studies that passed this initial process were then screened. The studies included in the review went on to a data extraction process and quality assessment. Each study was given a rating of ++ (high) + or – (low). Studies were classified according to intervention. Within each category evidence was provided using a narrative synthesis, supported by evidence tables, drawing out the key features of each review.
Criteria for inclusion of dementia organisation was that they be national/international organisations and that website was freely available, written in English and includes fact sheets, tips or suggestions for informal carers. Search of the websites was carried out by intervention type (as identified in the systematic review) and by behaviour/symptom type (again as identified in the systematic review). Where the web pages included links to, or referred to, additional pages or other sites these were also followed. Using content analysis the recommendations were grouped by intervention type and behaviour/symptom type.
Thirty five papers were included in the systematic review representing 33 studies. Four dementia organisations were included in the second part of the process.
Results
Effectiveness
The evidence from the systematic review suggests three different interventions are effective for symptoms of dementia: Music or music therapy, hand massage or gentle touch and physical activity or exercise. Music or music therapy had potential benefits for behavioural and psychological symptoms (including aggression, agitation and wandering) and cognition; massage for behavioural and psychological symptoms, in particular agitation; and physical activity for behavioural and psychological symptoms (mood, sleep and wandering). However even for these interventions the evidence is mixed or limited. For example, within the papers exploring music or music therapy methodological limitations were highlighted that included weak study designs and small sample numbers. Similarly evidence was presented for the use of massage or touch therapies and whilst there is evidence to suggest massage or touch therapies do work in a reducing agitation in the short term and can help with eating there was no conclusive evidence that massage reduces wandering, anxiety or aggressiveness. The evidence from the review dovetailed with the information given by the dementia organisations. All the dementia organisations suggested strategies that include music, physical activity or exercise and touch or massage.
In respect of non-drug treatments that might work, the majority of interventions fell into this category due to inconclusive results (Animal Assisted Therapy, Aromatherapy, Behaviour Management, Cognitive Stimulation, Environmental Manipulation, Light Therapy, Reality Orientation, Reminiscence Therapy, Multi-sensory Stimulation (MSS), Transcutaneous Electric Nerve Stimulation (TENS) and Validation Therapy). The lack of firm evidence arose primarily through conflicting results and weakness in study design. The implication for carers is that whilst some of these interventions might be useful in managing symptoms of dementia the evidence is not strong enough to support their use. However, some of the interventions in this group formed the backbone of the suggested coping/prevention strategies included in the dementia organisations’ websites.
Within the systematic review there was no evidence to suggest beneficial effects for two interventions, acupuncture and counselling. This was due to a dearth of studies that fit the review papers’ inclusion criteria. No randomised controlled trials were found for use of acupuncture for symptoms of dementia (Peng et al, 2007) and in line with the paucity of evidence none of the dementia organisations suggested its use.
Counselling was included in one paper (Bates et al, 2004). Whilst no evidence was demonstrated for improvements in cognitive function (recall logic, memory and learning) all the dementia organisations referred to counselling and/or cognitive behaviour therapy in the treatment of depression for people with dementia. Although Alzheimer Europe note, any kind of therapy which relies on verbal communication will only be suitable for a small number of people suffering from dementia or those in the early stages[3]
What strategies might carers try?
The focus of the strategies is behavioural and psychological symptoms of dementia. The strategies are an amalgamation of the findings from the systematic review and recommendations or suggestions from dementia organisations. The strategies are generic in as much as they do not apply to one specific type of dementia.
General strategies:
• To reduce behavioural and psychological symptoms of dementia create a relaxing environment paying attention to noise levels, lighting, music, other sensory stimulants like massage and touch. Pets may also have a calming effect
• In some cases difficult behaviours can be headed off or coped with by using an activity which provides a distraction from the behaviour or stops boredom. Carers might try music activities, activities with pets such as walking or petting the dog, sensory stimulation using massage or other touch therapies or activities that involve reminiscing. Physical activities can help use up spare energy, and provide a sociable activity giving routine and structure to the day
The following are activities or techniques that carers might like to try access locally. At the end of each suggestion the behaviour for which it might be beneficial is given in brackets.
• Training course for carers:
• Behaviour management techniques. Carers can also ask for an assessment of key factors that may improve challenging behaviour in those they are caring for (aggression, agitation, anxiety, depression, wandering)
• Techniques of validation therapy (aggression, depression, hallucinations)
o Interventions for the person with dementia:
• Animal Assisted Therapy (aggression, agitation, anxiety, depression)
• Bright light therapy (agitation, sleeplessness)
• Music therapy (aggression, agitation, anxiety, depression, hallucinations, wandering)
• Multi-sensory stimulation (aggression, depression, wandering)
• Reminiscence therapy (agitation, anxiety, depression, hallucinations)
• Counselling or cognitive behaviour therapy (depression)
• Cognitive stimulation therapy (depression)
• Reality orientation (depression)
Techniques or strategies that carers may try at home include:
• Having a pet in the home to encourage relaxation, to provide a distraction, provide comfort, stimulate conversation and provide the opportunity for exercise and social contact
• Use aromas (for example lavender oil) to create a calm environment
• Try massage or touch to soothe, to distract, encourage interaction, provide reassurance, encourage eating, or reduce wandering
• Create a calming environment by removing competing noises, ensuring lighting is adequate, using nightlights for reassurance
• Try using music as the focus of activity, sharing music together, encouraging singing clapping or even dancing
• Use background music to help create a calming environment
• Try different forms of physical activity. This can be formal classes such as tai chi or informal activities like housework
• Try activities that involve reminiscing e.g. looking at old photos or old books or making a family scrapbook
Conclusions
Overall the studies included in the reviews were characterised by weak study designs and small sample sizes. Indeed three reviews were unable to identify any studies of sufficient quality to assess. Many of the reviews included single person case studies or studies of less than five people. Whilst it is not possible to generalise about the effectiveness of different interventions many pointed to potential benefits from the intervention being assessed.
Many of the studies included were based in community residential settings (for example, in nursing homes). Given the increasing number of people now caring for people with dementia in their own home there is a clear need to ensure that research is transferable to this setting. Indeed, the International Psychogeriatric Association (IPA) note that further research is need to explore the relationship of behavioural and psychological symptoms of dementia to the environments in which they occur (IPA, 2002, p7)
Taken together, whilst the volume of studies in this area is encouraging the review points to the need for large, well designed, randomised controlled studies rather than the seemingly piecemeal approach taken at present.
The suggestions or recommendations made by dementia organisations appear to be based on existing research evidence together with suggestions from carers themselves about what works for them. The focus of these suggestions lies in behaviour and psychological symptoms. This is unsurprising given that virtually all patients with dementia will develop changes in behaviour as the disease progresses (Rayner et al, 2006, p647). Whilst the suggested strategies appear to be general, rather than specific across many behaviours the consensus opinion is that the incidence of distress can be ameliorated by a calming environment, structured activities and redirection or distraction (Lavretsky and Nguyen, 2006).
Whilst carers can apply some of the 16 interventions in the home setting at little or no cost to health or social care services (for example, playing favourite music), others are likely to require training (for example in hand massage) or instruction (for example, in appropriate exercise routines). Both service providers and commissioners should explore current and future provision of more structured group activities for people with dementia in line with the evidence presented; in particular the provision of group music therapy and group exercise activities that meet the needs of both the person with dementia and their carer.
ACKNOWLEDGEMENT
"This work was made possible by a generous bequest from the estate of Gilda Massari, whose wish was to fund research that produced practical benefit for the carers of people with Alzheimer's disease and related conditions. A version for carers is available from The Dementia Services Development Centre, University of Stirling, dementia@stirling.ac.uk "
SECTION ONE
Background
Dementia is used to describe a collection of symptoms, including a decline in memory, reasoning and communication skills, and a gradual loss of skills needed to carry out daily activities (Knapp et al, 2007); it is a non-reversible deterioration in memory, executive function and personality (Warner et al, 2006).
In the UK it is estimated that there are 700,000 people with dementia representing around one person in every 88 (1.1%) of the entire population (Knapp et al, 2007). This figure is set to increase to over 940,110 by 2021 (Knapp et al, 2007). Dementia is most common in older people; in the UK one in five people over the age of 80 years and one in 20 over the age of 65 years has a form of dementia (Knapp et al, 2007).
Typically dementia is reported under four categories: Alzheimer’s disease, vascular dementia, Lewy body dementia and frontal temporal dementia. All are characterised by problems with cognitive functioning and those with dementia are likely to experience behavioural and psychological symptoms (Warner et al, 2006).
Alzhiemer’s disease is the most prevalent type of dementia; in the UK Alzheimer’s accounts for around 6 out of 10 cases of dementia[4]. It is a progressive and eventually fatal disease (Yuhas et al, 2006, p35) of unknown etiology with characteristic neuropathological and neurochemical features[5]. It is characterised by an insidious onset and slow deterioration and involves impairments of speech, motor, personality and executive function (Warner et al, 2006). Alzheimer’s typically affects older people but can begin in younger individuals. Whilst the cause of Alzheimer’s is unknown risks factor include family history of the disease and advanced age (Griffiths and Rooney, 2006).
In the early stages of Alzheimer’s there are signs of memory loss that may include small behaviour changes, forgetting things or repeating things more than usual. In the next stage cognitive impairment becomes more evident and symptoms more disruptive (individuals struggle with activities of daily living and may neglect their personal appearance). In this stage individuals may need reminders to carry out activities of daily living and might have difficulty in recognising familiar places or people (Knapp et al, 2007). Over time, and in the final stages, there is increased dependency on others due to severe impairment of intellectual abilities. As physical functioning deteriorates individuals may become incontinent, unable to feed themselves and bedridden; speech is problematic and the individual may no longer engage in conversation. Eventually total care will be needed (Yuhas et al, 2006).
Vascular dementia, the second most common type of dementia in the UK, results from infarction of the brain due to vascular disease[6]. It is likely to occur suddenly (as a result of a transient ischaemic attack or stroke) and onset is usually later in life. Unlike the progression of Alzheimer’s disease, vascular dementia typically has a stepwise deterioration (impairment in memory, executive functions, and physical abilities) (Yuhas et al 2006, p36). However, because vascular dementia affects distinct parts of the brain it can leave particular abilities intact; those with vascular dementia may understand what is happening to them (because short term memory impairments are not always part of the initial presentation) which can lead to depression. Disruptive behavioural and psychological symptoms may appear at any stage of the illness. Behaviours that may be present include nocturnal confusion and wandering (Yuhas et al 2006). Progression may be slowed through control of underlying risk factors such as blood pressure (Knapp et al, 2007).
Lewy body dementia is a progressive dementia identified by abnormal structures in the brain cells called Lewy bodies (Yuhas et al 2006). Tiny spherical protein deposits develop inside the nerve cells in the brain interrupting the brain’s normal functioning, affecting memory, concentration and language (Knapp et al, 2007). This type of dementia is characterised by fluctuation of symptoms, the presence of early and prominent visual hallucinations and Parkinsonian symptoms (slow movement, bending slightly forward and shuffling when walking) (Yuhas et al 2006). Progression is more rapid than Alzheimer’s disease but short term memory is usually good. Those with this type of dementia can show marked fluctuations in alertness or cognition from hour to hour or week to week – characterised by confusion during which it is difficult to concentrate and complete tasks. Likely psychotic symptoms include paranoia, delusions and hallucinations which can be disruptive. People with Lewy bodies dementia are at risk of falls because of lack of an effective righting reflex and may experience restless leg syndrome which can interfere with sleep (Yuhas et al 2006).
Frontal temporal dementia is typically exhibited in those with a group of rare neurological disorders affecting the frontal and anterior temporal lobes of the brain; these include Pick’s disease, frontal lobe degeneration, and dementia associated with motor neuron disease (Yuhas et al 2006). It is likely to affect people under 65 and is characterised by gradual onset of changes in personality, social behaviour and language, dependent on whether damage has occurred in the left side (language) or right side (behaviour) of the front of the brain (Yuhas et al 2006). The later stages are characterised by difficulties with speech and language, memory loss and oral fixations. Behavioural and psychological disturbances are common (Yuhas et al 2006).
In the UK there is increasing focus on dementia. A recent report from the House of Commons Committee of Public Accounts acknowledged that dementia, despite its financial and human impact, has not received the same priority status as other diseases. It is estimated that in England alone late-onset dementia costs some £14.3 billion per year. This estimate includes the cost of care home accommodation (£5.72 billion, 40%) and an estimated saving to the taxpayer of £5.29 billion (37%) from the contribution made by informal carers (the NHS and social care make up the remainder; £1.14 billion 8% and £2.15 billion 15% respectively)[7].
The House of Commons report highlights the heavy burden carried by those caring for relatives with dementia at home. Indeed informal carers[8] deliver most of the care to people with dementia in the UK and many are elderly and frail themselves[9]. A National Dementia Strategy is planned for 2008[10].
Aim
The aim of this report is to help informal carers who want ideas about non-drug approaches for dementia, that they might try or that they could try to access.
Using a two part process, initially a systematic review was carried out in order to addresses the following questions:
• What non-drug treatments work and what do they work for?
• What non-drug treatments might work and what for?
• What non-drug treatments do not work?
The second part of the process searched the websites of four national (UK, USA and Australia) and international (Europe) dementia organisations to identify recommendations or suggestions for non-drug approaches for dementia. In each case the strategies identified from the websites were aligned with the non-drug treatments identified in the systematic review to produce a series of suggestions or ideas for informal carers about non-drug approaches for dementia, that they might try or access.
Methodology
The systematic review has been carried out by a team from the Institute of Health Sciences, University of Leeds.
Literature Search
The search strategy was developed by the review team at the University of Leeds. Literature searches of electronic databases and websites were then carried out. Comprehensive searches of the following databases were carried out on 7th November 2007:
• AMED (via OVID host)
• CINAHL (via OVID host)
• EMBASE (via OVID host)
• MEDLINE (via OVID host)
• PSYCINFO (via OVID host)
• Cochrane Library of Systematic Reviews (via Wiley host)
• DARE (via Wiley host)
The search strategies used can be found in Appendix 1.
Inclusion Criteria
1. Systematic reviews only (not reviews) including at least one randomised controlled trial of a non-drug intervention
2. English language
3. Non-drug treatments
4. The primary purpose of the review is to evaluate the effectiveness or efficacy evidence of one or more non-drug treatments for dementia
5. Reviews published from 2001 onwards
Exclusion Criteria
1. Management of dementia in acute settings
2. Management of dementia in long term care facilities/residential care settings
3. Assessment of dementia
4. Screening for dementia
5. Prevention of dementia
6. Guidelines for dementia
7. Herbal remedies/vitamin supplements
8. Generic reviews in gerontology
9. Interventions for caregivers (this refers to interventions for carers per se rather than interventions that carers can implement to help the person they care for)
The search yielded 784 unique references. Two stages of screening were used to determine which studies should be included in the review. Titles and abstracts of all 784 references were first screened. This first screening identified 114 potentially relevant papers. Full paper screening of the 114 references identified 35 papers to be included in the review representing 33 studies. Of the remaining, six provided background detail, 71 were excluded, and two were unobtainable in the time available. Reasons for exclusion are shown in box 1.
Box 1: Reasons for Exclusion from the Review
|Not systematic reviews only (not reviews) including at least one randomised controlled trial of a |57 |
|non-drug intervention | |
|Not English language |4 |
|The primary purpose of the review is not to evaluate the effectiveness or efficacy evidence of one or |6 |
|more non-drug treatments for dementia | |
|Guidelines |2 |
|Not received in time to be included |2 |
|Précis of a review only |1 |
|Withdrawn |1 |
|Background only |6 |
|Total |79 |
Quality Appraisal
Data relating to the scope of this review was extracted from each study using the National Institute of Clinical Excellence (NICE) data extraction template (NICE 2006). Methodological checklists (NICE 2006) were applied to each study to determine the quality of each study. The checklist states that in a well-conducted systematic review:
▪ The study addresses an appropriate and clearly focussed question
▪ A description of the methodology used is included
▪ The literature search is sufficiently rigorous to identify all relevant studies
▪ Study quality is assessed and taken into account
▪ There are enough similarities between the studies selected to make combining them reasonable (NICE 2006, p112)
Each study was given a rating of ++ (high) + or – (low). Studies assessed ++ are those in which all or most of the above criteria on the checklist are fulfilled. Where the criteria are not fulfilled the conclusions the review comes to are thought very unlikely to alter. For those assessed + some of the above criteria is fulfilled. Those not fulfilled or adequately described are thought unlikely to alter the review’s conclusions. A rating of – is applied where few or none of the above criteria are fulfilled. Had they been fulfilled the review’s conclusions are likely or very likely to alter.
Studies were categorised according to intervention type. Within each of these categories evidence is provided using a narrative synthesis, supported by evidence tables, drawing out the key features of each study. Evidence is provided in a hierarchy with higher quality studies ranked first in the evidence tables.
Dementia Organisations
Criteria for inclusion of dementia organisation was that they be national/international organisations and that website was freely available, written in English and includes fact sheets, tips or suggestions for informal carers. Search of the websites was carried out by intervention type (as identified in the systematic review) and by behaviour/symptom type (again as identified in the systematic review). Where the web pages included links to, or referred to, additional pages or other sites these were also followed.
Using content analysis the recommendations were grouped by intervention type and behaviour/symptom type. The search was stopped at four dementia organisations as saturation was achieved. The organisations and website address are shown below.
Four national/international dementia websites were included:
• Alzheimer’s Society (UK)
• Alzheimer’s Association (USA)
• Alzheimer’s Australia (Australia)
• Alzheimer Europe
SECTION TWO
Review of Effectiveness
The review identified 35 papers representing 33 studies (2 papers reported on the same studies) which met the inclusion criteria. In addressing the review questions:
• What non-drug treatments work and what do they work for?
• What non-drug treatments might work and what for?
• What non-drug treatments do not work?
Interventions
The studies were grouped by intervention into 16 key areas:
• Acupuncture
• Animal Assisted Therapy
• Aromatherapy
• Behaviour Management
• Cognitive Stimulation Therapy/Cognitive Training
• Counselling
• Environmental Manipulation
• Light Therapy
• Massage/Touch
• Music/Music Therapy
• Physical Activity/Exercise
• Reality Orientation
• Reminiscence Therapy
• Snoezelen/Multi-sensory Stimulation
• TENS
• Validation Therapy
Symptoms
The symptoms of dementia addressed in the papers include in the review were varied and ranged from the specific to the general. In order to make sense of these, each has been grouped into one of the three main types symptoms typically displayed by people with dementia (see box 2 below). The three main types of symptom are: loss of cognitive function, impairment of the ability to perform activities of daily living (ADLs) and abnormal behaviour[11]. Loss of cognitive function often manifests itself in memory loss whilst impaired functional ability can affect, for example, a person’s ability to get dressed or brush their teeth. Abnormal behaviour covers both behavioural and psychological symptoms. Indeed the term behavioural and psychological symptoms (BPSD) is used to describe the non-cognitive manifestation of dementia (Bianchetti and Trabucchi, 2004). The groupings used by Bianchetti and Trabucchi have been used inform the classification of symptoms.
Box 2: Types of Symptoms
|Cognitive Ability |Ability to perform activities of |Behavioural and psychological symptoms |
| |daily living | |
|Cognitive Function |Functional Ability |Aggression |
|Communication |Quality of Life/Well-being |Agitation |
|Learning | |Anxiety |
|Memory | |Apathy |
|Recall | |Behaviour |
| | |Depression |
| | |Emotional and Behavioural Responses |
| | |Inappropriate Behaviour |
| | |Mood |
| | |Neuropsychiatric Symptoms |
| | |Nutrition |
| | |Psychological Symptoms |
| | |Sleep |
| | |Social Behaviour |
| | |Wandering |
Interventions and Symptoms
Matrix 1 on page 114 cross references the individual symptoms to intervention type to give a summary of evidence of effectiveness. Box 3 (below) provides a précis of the type of symptom and intervention. For example, Cognitive Stimulation Therapy or Training was used to address symptoms in all three categories whereas Animal Assisted Therapy was used only to address behavioural and psychological symptoms.
Box 3: Interventions and Smptoms
|Cognitive Ability |Ability to perform activities of daily living|Behavioural and psychological symptoms |
|Cognitive Stimulation Therapy/Cognitive|Cognitive Stimulation Therapy/Cognitive |Animal Assisted Therapy |
|Training |Training |Aromatherapy |
|Counselling |Physical Activity/Exercise |Behaviour Management |
|Light Therapy |Reality Orientation |Cognitive Stimulation Therapy/Cognitive|
|Music/Music Therapy |Snoezelen/Multi-sensory Stimulation |Training |
|Physical Activity/Exercise | |Environmental Manipulation |
|Reality Orientation | |Light Therapy |
|Reminiscence Therapy | |Massage/Touch |
|Snoezelen/Multi-sensory Stimulation | |Music/Music Therapy |
|TENS | |Physical Activity/Exercise |
|Validation Therapy | |Reality Orientation |
| | |Reminiscence Therapy |
| | |Snoezelen/Multi-sensory Stimulation |
| | |TENS |
| | |Validation Therapy |
Overview of Papers
The majority of papers identified in this review were concerned with dementia in a generic sense in as much as they did not identify one type of dementia or a specific stage of dementia. The focus of the six papers that were more specific were Alzheimer’s disease (Clare & Woods, 2003; Grandmaison & Simar, 2003; Penrose, 2005; Sitzer et al, 2006), vascular dementia (Clare & Woods, 2003: Peng et al, 2007) and milder dementia or early stage dementia (Clare & Woods, 2003; Bates et al, 2004). The samples within the studies typically consisted of older people.
Overall the research studies presented within the reviews identified were characterised by weak study designs with small sample numbers. This meant that three of the reviews included (Hermans et al, 2007; Peng et al, 2007; Price et al, 2001) presented their objectives, search strategies and selection criteria but did not find any suitable studies for inclusion in their reviews. The study inclusion criteria for Hermans et al (2007) and Peng et al (2007) included only randomised controlled trials; Price et al (2001) also included controlled trials and interrupted time series. Details of these studies are presented in tables 1 and 17. Reference is also made to them where appropriate in the text.
Interventions
Acupuncture
Traditional acupuncture is used to treat a wide range of illnesses.[12] The treatment involves fine needles being inserted through the skin and briefly left in position. The number of needles varies but may be only two or three[13]. Only one review was identified that attempted to explore the use of acupuncture (Peng et al, 2007). A summary of the key characteristics of the review are given in table 1, p116.
Peng et al aimed to assess the efficacy and possible adverse effects of acupuncture therapy for treating vascular dementia. To be included in the review studies should be randomised controlled trials, participants with a diagnosis of vascular dementia according to accepted criteria, and research comparing any type of acupuncture therapy with placebo or no intervention. The review did not identify any studies that met the criteria and thus has not been given a quality rating.
Summary
No evidence was identified to support the use of acupuncture for those with vascular dementia.
Animal Assisted Therapy (AAT)
Formally AAT most commonly involves interaction between a client and a trained animal, facilitated by a human handler, with a therapeutic goal such as providing relaxation or pleasure, or incorporating activities in physical therapy or rehabilitation (Filan & Llewellyn-Jones, 2006, p598).
Thus, AAT may simply be to focus on the animal for a specified time (for example grooming a dog or petting it). This can promote conversation or physical activity or promote conversation about previous pets which increases over time[14]. Indeed studies in the 1980s indicated that pets promoted dialogue among family members and contributed to well-being (Wilson & Turner, 1998). However, it is reported that the benefits of therapy pets vary a lot by the individual[15].
Two reviews (Filan & Lllewellyn-Jones, 2006; Cohen-Mansfield, 2001) considered the use of animals as part of the therapeutic process for those with dementia with the aim of reducing agitation and/or aggression, promoting social behaviour and improving nutrition. A summary of the key characteristic of the reviews are provided in table 2, p117-118.
Whilst many of the studies included in the reviews consider AAT in terms of a trained animal and therapist others consider the presence of a dog or cat in the home (both in a residential and private setting) either full time or for short periods of time to reduce agitation and/or aggression and promote social behaviour. Indeed it has been suggested that the presence of an animal can provide a sense of meaning, diversion and serendipity; that companion animals provide unconditional positive regard in stages of Alzheimer’s disease where normal avenues of communication fail (Baum & McCabe, 2003). They go on to suggest that caregivers might also benefit from the stress reduction that results from petting a familiar companion animal (p44).
The first review of 11 studies (Filan and Lllewellyn-Jones, 2006), which was assessed as +, appraised studies that have investigated whether AAT has a measurable beneficial effect for people with dementia and specifically upon behavioural and psychological symptoms of dementia. The study interventions included ‘pet visits’, the introduction of a resident dog and introduction of aquaria.
Six studies within the review reported on the impact on anxiety and aggression (of either the introduction of a dog or cat at specified periods or a ‘resident’ dog); all report at least one significant, positive result. Four assess the impact on social behaviour (of either the introduction of a dog or cat at specified periods or a ‘resident’ dog); all report positive results. One study reported on the impact on nutrition and reports a significant increase in food intake and monthly resident weight when a fish tank is introduced in the dining area of a nursing home. The review concludes that AAT appears to offer promise as a psychosocial intervention for people with dementia. However, the optimal frequencies and duration of AAT sessions, as well as the optimal format of such sessions, need systematic study.
The review is hampered by lack of detail in the study design; some aspects of study design are not clear, for example whether samples were randomised. The small sample sizes and selection criteria are likely to over estimate the results. The authors point to several limitations in the studies reviewed; these include potential bias when participants have a prior history of positive interaction with animals, small sample sizes, and unclear duration of impact.
The second review, Cohen-Mansfield (2001) was rated as -. The review appraised the impact of non-pharmacological interventions on inappropriate behaviours in dementia and identified three AAT studies. All three studies reported positive results (the interventions are: certified dog therapy for two 30 minute sessions, companion animals and a pet dog for one hour a day for five days). However, in the latter study only 22% of participants had been diagnosed with dementia. There is little quality assessment within the review in respect of the type of study design (RCT, case study etc) which means that all the studies included appear to be given equal weight. Methodological issues are presented within the discussion section, these relate to diverse measurement methods, criteria for success, screening procedures, control procedures and treatment of failures.
Summary
The majority of studies in the reviews conformed to the definition of AAT in as much as they included a trained animal (usually a dog) and trained handler rather than evaluating the impact of having a pet per se.
The studies that explored use of AAT (typically the introduction of a dog or cat at specified periods or a ‘resident’ dog) report positive results in behaviour and psychological symptoms (reducing agitation and aggression, improving social behaviours including more interaction and longer duration of smiles). However, as noted by Filan and Lllewellyn-Jones, the studies were characterised by small sample numbers, include potential bias when participants have a prior history of positive interaction with animals and duration of any improvement is unclear. The lack of detail in reporting the studies (even where it is clear there is a control group, it is unclear whether participants have been randomly assigned to the groups) means that the evidence is not robust.
The conclusion drawn is that AAT might work to reduce aggression and agitation, improve social behaviour and improve nutrition. However, further research that addresses the above limitations is required in order to provide evidence that it does work.
Aromatherapy
Aromatherapy is the systematic use of essential oils in holistic treatments with the aim to improve physical and emotional well-being. It is reported that essential oils, extracted from plants, can be utilised to improve health and prevent disease and are applied in a variety of ways[16]. Essential oils may be incorporated through massage, by adding a few drops to baths or by inhalation (for example, by way of a diffuser).
Three systematic reviews (Thorgrimsen et al, 2003, 2006; Robinson et al, 2006, 2007; Diamond et al, 2003) explored the effectiveness of aromatherapy in reducing behavioural and psychological symptoms (agitation, neuropsychiatric symptoms and wandering). A summary of the key characteristic of the reviews are provided in table 3, p119-120.
Thorgrimsen et al (2003, 2006), in their review, rated ++, appraised two randomised controlled trials. The first compared use of lemon balm (Melissa) plus a base lotion against sunflower oil both applied to the arms and face twice daily over four weeks. Additional analyses of the study data revealed a statistically significant treatment effect in favour of the aromatherapy intervention on measures of agitation and neuropsychiatric symptoms, but there were several methodological difficulties with the study. The second trial in the review compared the effects of lavender applied through massage, lavender applied through a diffuser accompanied by conversation and conversation alone. No statistically significant difference was found between groups.
Similarly Robinson et al (2006, 2007) in their review (again rated ++) reported on two randomised controlled trials (the first is the same lemon balm trial reviewed by Thorgrimsen et al, the second compares lemon balm and lavender with neutral control oil). Overall the review reported no robust evidence of the efficacy and the evidence was deemed to be of low quality. The first randomised controlled trial reported that participants receiving essential oils showed less wandering behaviour (marginal statistical significance); the second found no difference between groups.
Diamond et al (2003) (rated -) included seven aromatherapy studies within their review. The review included both the randomised controlled trials in Robinson et al. Diamond et al reported that aromatherapy may have moderately beneficial effects; but that better controlled studies with larger sample sizes are needed to evaluate the effect of aromatherapy on the affect and behaviour of persons with dementia. The review was rated – because study quality was not assessed within the review, all the studies included were given equal weight.
Summary
There is some evidence that aromatherapy might reduce agitation, neuropsychiatric symptoms and wandering. However, relatively few studies were identified within the reviews and the evidence that was presented was not robust. The randomised controlled trials within the reviews produced conflicting results in terms of their effectiveness. These conflicting results may be a result of differences between interventions (for example, the oils use). All reviews suggested that better controlled studies with larger sample sizes are needed to evaluate the effect of aromatherapy.
Behaviour Management
Behaviour management covers a wide spectrum of techniques to address challenging behaviour. Some of these are addressed in separate sections within this review (for example environmental manipulation to manage wandering)
Three studies were found that included behaviour management studies (Robinson et al, 2006, 2007; Verkaik et al, 2005; Livingston et al 2005). Of interest in the reviews was the effect on wandering, depression, aggression, apathy and neuropsychiatric symptoms. The interventions under the behaviour management umbrella included social skills training, problem solving and behavioural reinforcement. A summary of the key characteristic of the reviews are provided in table 4, p121-122.
Robinson et al (2006, 2007) reviewed the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in those with dementia. The review, rated ++, identified one study evaluating the effectiveness of individualised behaviour management. This study, a non-randomised control trial, did not provide evidence that the intervention was effective in preventing/reducing wandering.
The second review (Verkaik et al, 2005; rated +) again included only one behaviour management study, although this was not the same study included in the Robinson review. The review assessed the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia; the study focussed on the use of behaviour therapy for alleviating depression. Verkaik et al concluded that there is limited evidence (one high quality randomised controlled trial) that people with probable Alzheimer’s disease living at home with depression are less depressed when their caregivers are trained in using behaviour therapy-pleasant events or behaviour therapy-problem solving rather than given standard information from a therapist or no information/training.
The final review to include behaviour management interventions (Livingston et al, 2005; rated +) explored psychological approaches to the management of neuropsychiatric symptoms of dementia. Twenty five papers in the review reported on non-dementia specific psychological therapies for patients with dementia. Nearly all of the studies examined behavioural management techniques. The studies were judged to be of relatively low quality (rated 4 on a scale of 5 where a lower number indicates higher quality). The authors reported that the findings of the larger randomised controlled trials were consistent and positive, and the effects lasted for months. However, perusal of the table of evidence provided in the review does not appear to bear these conclusions out. Three randomised controlled trials report conflicting results in respect of behavioural changes; the first (n=89) reports no reduction in disruptive behaviour whilst the second (n=17) saw a significant reduction in behavioural symptoms and the third (n=8) found reduced social aggression. Similarly one randomised controlled trial (n=42) found behavioural management techniques significantly reduced depression whilst another (n=8) found no effect on depression.
Summary
The reviews have shown that behavioural management interventions might work in alleviating some behavioural and psychological symptoms of dementia. However evidence of their effectiveness in respect of reducing wandering, depression, aggression, apathy and neuropsychiatric symptoms is inconclusive. Whilst a number of randomised controlled trials were identified they were characterised by small sample numbers. Of the two randomised controlled trials with larger sample sizes (n=89 and n=72) only one reported a positive result (reduction in depression scores). Well constructed and designed trials with larger sample sizes are required.
As the reviews indicate carers may apply behaviour management techniques. The techniques are usually structured, systematically applied, time limited and, importantly, carried out under the supervision of a professional with expertise in the area[17].
Cognitive Stimulation Therapy /Cognitive Training
General cognitive stimulation involves a range of group activities and discussions aimed at enhancing cognitive and social functioning; similarly cognitive training involves guided practice on a set of standard tasks designed to reflect memory, attention, language or executive function (Clare and Woods 2004).
Five reviews assessed evidence in this area (Clare & Woods, 2003; Grandmaison & Simard, 2003; Sitzer et al, 2006; Bates et al 2004; Livingston, 2005). Two were rated as ++ (Clare & Woods, 2003; Sitzer et al, 2006) and three as +. Focus of the reviews was improved memory and cognitive functioning, and management of neuropsychiatric symptoms. A summary of the key characteristic of the reviews are provided in table 5, p123-125.
Clare and Woods (2003) reviewed the evidence of the effectiveness and impact of cognitive training and cognitive rehabilitation interventions aimed at improving memory and other aspects of cognitive functioning for people in the early stages of Alzheimer’s disease or vascular dementia. The review included nine studies, all randomised controlled trials. The interventions included cognitive skills remediation training, memory training or coping programmes and cognitive training. The authors reported no significant benefits of cognitive training stating that the available evidence is limited; there is no indication of any significant effects from cognitive training. However, they suggested that the use of standardised neuropsychological measures may result in positive effects on daily living capabilities going unrecognised. Similarly, the review is unable to draw any conclusion about the efficacy of individualised cognitive rehabilitation interventions for people with early stage dementia due to lack of randomised controlled trials.
The Sitzer et al (2006) review was rated as ++. The review performed a meta–analysis in order to review the literature and summarise the effect of cognitive training for Alzheimer’s disease. The studies included under the cognitive training umbrella include a diverse range of interventions (including reality orientation and reminiscence therapy). The authors group the studies into either compensatory strategies (that aim to teach new ways of performing cognitive tasks by working around cognitive deficits) and restorative strategies (that aim to improve functioning in specific domains with the ultimate goal of returning function in those domains to pre-morbid levels). Using Cohen’s d, effect sizes were calculated for each cognitive domain. The authors concluded from the analysis that cognitive training evidenced promise in the treatment of Alzheimer’s disease with primarily medium effect sizes for learning memory, executive functioning, activities of daily living, general cognitive problems, depression and self-rated general functioning. Restorative strategies demonstrated the greatest effect on functioning. They note however that the results are limited due to the small number of well controlled studies, small sample numbers and difficulties associated with outcome measures. Overall the review was well presented with clear analysis. However, the diversity of the interventions included mean that only broad conclusions may be drawn. It is of interest that studies identified as higher quality ‘painted a less optimistic picture of efficacy’.
A review of memory stimulation programmes (Grandmaison & Simard, 2003), rated +, assessed evidence of the efficacy of stimulation strategies or programmes in Alzheimer’s disease. The 17 studies included cover visual imagery, encoding specificity strategies, errorless learning, external memory aids and dyadic training. The review concluded that it is possible to stimulate memory in Alzheimer’s disease. The errorless learning, spaced retrieval, and vanishing clues techniques, together with the dyadic approach seem to present the best training methods for patients with Alzheimer’s disease but there is a need for more randomised trials to validate the treatment approaches. The review itself was comprehensive but inclusion of only two databases for the search may have led to the exclusion of pertinent studies. As the authors indicated, whilst the evidence suggests positive results the majority of studies contain small sample numbers making identification of statistically significant improvements difficult.
Bates et al (2004), in their review rated +, investigated the effectiveness of psychological interventions for people with milder dementing illness. They included one memory stimulation study. The study found no significant improvement in functional and cognitive ability and thus the review did not find any evidence of the effectiveness of procedural memory stimulation.
The final review (Livingston et al, 2005), rated +, explored the management of neuropsychiatric symptoms. Livingston et al assigned the evidence from the four papers a grade representing mostly consistent evidence that cognitive stimulation therapy improves aspects of neuropsychiatric symptoms immediately and for some months afterwards. All four studies were randomised controlled trials, three of the four showed positive improvements (fewer behavioural problems but returning to baseline at nine month follow up, significant decrease in depression, improvement in quality of life). Overall the review is comprehensive but it is limited by lack of detail. Two of the studies included in this review (Quayhagen et al, 1995, 2000) are also included in the Clare & Wood review. Whilst Livingston et al do not comment on the study design other than to assign a grade representing ‘mostly consistent evidence’, Clare & Wood point to methodological limitations including those relating to randomisation, performance and attrition bias in both studies.
Summary
In line with the aims of cognitive stimulation therapy or training, the studies within the review reflected all three main symptoms types (behavioural and psychological symptoms, cognitive function and ability to perform ADLs). The reviews point to potential benefits from cognitive rehabilitation and training – that it might work for improving memory, cognitive functioning, neuropsychiatric symptoms, behaviour, depression, quality of life, learning, and activities of daily living. The evidence presented is inconclusive. The studies included in the reviews were primarily of small sample size and whilst a number of randomised controlled trials have been carried out these appear to have methodological limitations. The meta-analysis carried out by Sitzer et al (2006) produced encouraging results reporting medium effect sizes for learning memory, executive functioning, activities of daily living, general cognitive problems, depression and self-rated general functioning. However the interventions included in the analysis, under the umbrella of cognitive training, were diverse. The review did not point to the effectiveness of any one type of cognitive training.
Counselling
Bates et al (2004) included counselling interventions in their review of psychosocial interventions for people with milder dementing illness (see table 6, p126). The review, rated +, identified just one randomised controlled trial. They reported that counselling provided an opportunity for the client to vent their concerns and receive validated information about their mental status. However, the effectiveness of individual counselling sessions were not demonstrated on the outcome measures used (addressing recall, logical memory, and learning). The sample size of the study was small (n=20).
Summary
There is no evidence that counselling works for improving cognitive function (recall, logic memory or learning). However, this statement should be tempered with the caveat that only one randomised controlled trial was identified within the review and this had a small sample size.
Environmental Manipulation
Three reviews (Livingston, 2005; Cohen-Mansfield, 2001; Spira & Edelstein, 2006); considered studies that manipulated the environment to effect changes in neuropsychiatric symptoms and inappropriate behaviours including agitation. A summary of the key characteristic of the reviews are provided in table 7, p127-128.
A review of psychological approaches to the management of neuropsychiatric symptoms of dementia (Livingston, 2005; rated +) identified 19 studies using some form of environmental manipulation. The studies within the review addressed a multitude of different behavioural challenges including wandering, aggression and agitation. Eight studies within the review investigated the effects of changing the visual environment; the authors assessed that there was consistent evidence from lower grade studies for changing the environment to obscure the exit (to reduce wandering). Two studies that investigated the use of mirrors found inconclusive/inconsistent evidence (in reduction of agitation and wandering). Similarly the evidence from three studies that investigated use of signposting was judged inconclusive/inconsistent.
Cohen-Mansfield (2001; rated -) reviewed the impact of non-pharmacological interventions on inappropriate behaviours. Of the six ‘environment’ studies identified two studies showed free access to an outdoor area resulted in decreased agitation; two found a simulated natural environment decreased agitated behaviours; and two report reduced agitation after initiation of a reduced stimulation environment. All the studies have small sample number and little account is taken of study design by the review.
The Spira & Edelstein review (2006; rated -) of behavioural interventions to reduce agitation in older adults with dementia identified six ‘environment’ studies. In respect of wandering and hazardous behaviour the authors report that taken together the six studies show the intervention can have clinically meaningful effects on wandering in older adults with dementia; but contradictory results were obtained concerning the utility of particular stimuli. Only one study, a single subject case study assessed disruptive vocalization. The review is limited in as much as only one database was searched which is likely to have limited papers identified. Unfortunately the prevalence of single subject and case study designs together with the majority of studies measuring the occurrence of target behaviours by direct observation means this evidence is at best weak and likely to over estimate the results.
Summary
The interventions included in this category were diverse; they included the use of mirrors, sign-posting and access to outdoor areas. The studies were characterised by small sample sizes and were typically of low quality. Indeed even between similar interventions the results were generally conflicting. The absence of robust studies (in particular randomised controlled studies) meant it was only possible to conclude that environmental manipulation might work for improving behavioural and psychological symptoms, specifically neuropsychiatric symptoms, agitation and wandering. Further evidence of effectiveness is needed.
The studies included in the review were based in residential or institutional settings and as such may not be easily transferable to a home setting. However, access to an outside area such as a garden (rather than being confined indoors) may be useful in deceasing agitation or aggression.
Light Therapy
Light therapy involves exposure to intense levels of light under controlled conditions[18]. The four papers in this section (Forbes et al, 2007; Skjerve et al, 2004; Kim et al, 2003; Cohen-Mansfield, 2001) explored the use of light therapy to manage sleep, behaviour, mood, cognition, agitation and psychological symptoms in people with dementia. A summary of the key characteristic of the reviews are provided in table 8, p129-131.
The first review, Forbes et al (2007) rated ++, reviewed the efficacy of light therapy in managing disturbances of sleep, behaviour, mood and/or cognition associated with dementia. Five studies were included in the review, all were randomised controlled trials. Within the five studies bright light therapy (BLT) was typically administered by a BriteliteTM box placed about 1 metre from the participants head. The review concluded that the effects of BLT on sleep, behaviour and mood disturbances associated with dementia revealed little significant evidence of benefit; that the available studies were of poor quality and further research is required.
Skjerve et al (2004) explored the efficacy, clinical practicability and safety of light treatment for behavioural and psychological symptoms of dementia. The review, rated +, identified substantially more studies than the Forbes et al review (n=21) but, unlike Forbes et al, did not restrict its criteria to randomised controlled trials. Studies within the review were characterised by small sample sizes. Six of the 21 studies were randomised controlled trials and despite these trials (one with good power) showing some positive results the authors did not draw any conclusions on efficacy. Instead, they recommended study into the effects of BLT on those with mild dementia suggesting that successful treatment may be more likely for this population and may reduce the need for institutionalisation. They suggested that the different effects may be due to differences in treatment (brightness, duration, and timing) or condition (e.g. vascular dementia) which have been insufficiently tested. Whilst the Skjerve et al review is comprehensive, the process of study selection, extraction and synthesis are not presented.
Kim et al (2003) evaluated the effects of bright light therapy on the sleep and behaviour of dementia patients. From the 14 studies assessed they found evidence for effectiveness inconclusive; that there is a need for controlled studies to look at the relationship between dementia, agitation, sleep-wakefulness and bright light in community or nursing home populations. Assessment of the review (rated -) was constrained by lack of details pertaining to the literature search and the wide inclusion criteria which could overestimate effects.
Similarly Cohen-Mansfield (2001), in a review of the impact of non-pharmacological interventions on inappropriate behaviour, report that the results in the seven papers identified were inconclusive, some studies showed a significant decrease whilst others reported a trend. The authors suggested that these differences may stem from differences in design and measurement or from differences in population. The volume of studies included in the overall review (n=83) mean that some, but not all of the studies are described, but all are given equal weight. The review was rated -.
Summary
The four reviews agreed that the evidence for the use of light therapy was inconclusive; that light therapy might work when used to improve behavioural and psychological symptoms (sleep, behaviour, mood, agitation) and cognition . Whilst research has reported positive effects, the studies have been of poor quality; in particular well designed randomised controlled trials are needed. In addition, as indicated by Skjerve et al, whilst the majority of studies included in the reviews used some form of bright light lamp, the different effects may be due to differences in treatment (brightness, duration, timing) or condition (e.g. vascular dementia) which have been insufficiently tested.
Massage/Touch Therapies
Three reviews appraised the use of massage or touch therapies (Viggio Hansen et al, 2006; Livingston et al, 2005; Cohen-Mansfield, 2001). Of interest are behavioural and psychological symptoms (nutrition, agitation, wandering, anxiety and aggression). A summary of the key characteristic of the reviews are provided in table 9, p132-133.
Viggio Hansen et al (2006) assessed the effectiveness of massage and touch therapies offered to patients with dementia (rated ++). Only two randomised controlled trials were included in their review. The interventions are gentle touch on the forearm accompanying encouragement to eat and hand massage (and calming music with hand massage). The former study reported a significant increase in mean intake of calories as well as protein in the group receiving verbal encouragement and touch (but no change in control). The latter study found a decrease in agitated behaviour greater in the group receiving hand massage than that in usual care. The review concluded that some evidence is available to support the efficacy of two specific applications: the use of hand massage for an immediate and short term reduction in agitated behaviour, and the addition of touch to verbal encouragement to eat for the normalization of nutritional intake.
A second review, Livingston et al (2005) rated +, reviewed psychological approaches to the management of neuropsychiatric symptoms of dementia. The authors identified three studies in this area only one of which is a randomised controlled study. The authors reported no evidence for sustained usefulness. However, the randomised controlled trial (the same study as reported by Viggio Hansen et al) that compares calming music, hand massage, music followed by massage or music and massage simultaneously for 10 minutes each, finds all groups had reduced agitation relative to usual care. The effect lasted one hour.
The final review (Cohen-Mansfield, 2001), assessed as -, identified six studies that evaluated massage or touch therapies. The aims of the studies included one or more of the following: reduced wandering, agitation/anxiety and aggressiveness. Four appraised hand massage, one back massage; one is merely described as slow stroke massage. One study reported unequivocal success, the others either a positive trend, partial effects (physical and verbal behaviours) or no effect (aggression). The study designs were not clear. The large number of studies included in the overall review mean that some, but not all of the studies are described, but all are given equal weight.
Summary
There is evidence to suggest massage or touch therapies work in a number of areas. The evidence suggests:
• Hand massage; music followed by hand massage or music and massage simultaneously each for 10 minutes can have an immediate effect and short term reduction in agitated behaviour
• Gentle touch on the forearm accompanying verbal encouragement can increase mean intake of calories
However, there is no conclusive evidence that massage reduces wandering, anxiety or aggressiveness.
Music / Music Therapy
Music and music therapy has been advocated as offering possible beneficial effects on symptoms of dementia including social, emotional and cognitive skills and for decreasing behavioural problems (Koger & Brotons, 2000). Even when other abilities are seriously affected, many people still enjoy singing, dancing and listening to music[19]. Approaches to music therapy differ but key to all is the development of a relationship between client and therapist[20]. Music therapy typically includes one or more of the following: listening, singing or playing; the process may take place in individual or group sessions[21].
Ten systematic reviews (Sung & Chang, 2005; Vink et al, 2003; Sherratt et al, 2004; Lou, 2001; Nugent, 2002; Robinson et al, 2006, 2007; Warner et al, 2006; Livingston et al, 2005; Watson & Green, 2006; Cohen-Mansfield 2001) explored the effects of music and music therapy on the treatment of those with dementia. Five of the reviews focussed only on music and music therapy for the treatment of dementia; five were more general reviews that included an assessment of the evidence on music and/or music therapy for the treatment of dementia. A summary of the key characteristic of the reviews are provided in table 10, p134-139.
The reviews considered the use of music therapy for a number of symptoms including effectiveness in reducing agitated behaviour and wandering, management of neuropsychiatric symptoms, nutrition, and, more generally, emotional and behavioural responses, behavioural, social, cognitive and emotional problems and cognitive, behavioural and psychological symptoms. The majority of reviews considered a range of music and music therapies; only one (Sung & Chang, 2005) limited their review to ‘preferred music’. None confined use of music therapy only to those with Alzheimer’s disease but rather explored use of music therapy with those with dementia. The reviews were of mixed quality, four were assessed to be ++, three + and three -. With the exception of Vink et al (2003) study design was not restricted to randomised controlled trials.
The Vink et al (2003) review, rated ++, assessed the efficacy of music therapy in the treatment of behavioural, social, cognitive and emotional problems of older people with dementia. Five studies were included in the review; all were randomised controlled trials. Three compared music listening with a control intervention or no intervention. The interventions included playing a patient’s preferred music compared with classical music to reduce agitation; playing preferred music during bath time to reduce occurrences of aggressive behaviour; and group music activities including listening, singing and playing compared with group reading sessions in reducing wandering behaviour. All reported music listening more effective than the control or no control. A further study compared music group therapy with conversation sessions and music therapy (intervention appears to be based primarily on singing) and the affect on language functioning. It reported music therapy to be more effective. The final study compared music therapy with puzzle activities and general activities and again was reported to be more effective in improving social and emotional functioning. However, Vink et al assessed that none of the studies presented any of the quantitative results in sufficient detail to justify the conclusions drawn.
Sung and Chang (2005) provided a summary of the effects of preferred music on agitated behaviours for older people with dementia. The review included eight studies (two of which were included in the Vink et al review). Whilst these two were randomised controlled trials the other studies were of a variety of designs (case study, case control, cross over with participant as own control) characterised by small sample numbers (four studies n≤5). The interventions included playing preferred music during the day and playing preferred music during bath time. The findings from the majority of included studies are positive in reducing agitated behaviours. Sung and Chang concluded that music listening interventions matched with personal preferences have positive effects in reducing occurrence of some forms of agitated behaviours in older people with dementia; but a number of methodological limitations were apparent in the studies reviewed. The review, rated ++, provides a comprehensive description of methodology, literature and findings; of particular strength is the concentration on the use of preferred music only which adds consistency.
Sherratt et al (2004), rated +, reviewed 21 clinical studies looking at the effects of a variety of music on the emotional and behavioural responses in people with dementia. Whilst many of the studies included in the review mirror those included in the Vink et al and Sung and Chang reviews the study designs are not clearly described. The interventions include group music activities and listening to music. The majority of studies reported positive effects. Music was found to be effective in decreasing a range of challenging behaviours including aggression, agitation, wandering, repetitive vocalizations and irritability. Music was also found to increase reality orientation scores, time spent with one’s meal and social behaviour. Whilst the review was comprehensive and discusses a number of methodological issues (including, for example, observational data collection methods) it does not address study design in relation to assessment of quality.
Lou (2001) reviewed interventions that use music to decrease agitated behaviour of the demented elderly person. All papers identified for the review were included in one or more of the reviews above. The interventions were all music listening (albeit some described as background music). Lou concluded that music can be useful as an intervention to help patients deal with agitated behaviour problems and can increase patients’ quality of life but that weakness and limitations in study design are considerable. The review was rated -, because the search strategy is not clear in as much as inclusion criteria is preferably with demented elderly and no details are given of the numbers of papers identified in initial screening. Limiting the search to two databases may have reduced the papers identified.
The final review whose focus was solely music and music therapy, Nugent (2002), examined the use of music and music therapy for people who have Alzheimer’s disease and related disorders (ADRDs) and display agitated behaviours. The review, rated -, supported the premise that music and music therapy interventions reduce the occurrence and frequency of agitated behaviours, that music therapy may prevent extreme forms of agitation and that the studies demonstrate that wandering and general restlessness is reduced significantly. However, the author acknowledged that more rigorous designs that include refined measuring tools and studies that have larger sample sizes are required to gather more data. The author’s conclusions were likely to overstate the effectiveness of the interventions as all studies were given equal weight irrespective of study quality and there is insufficient detail or assessment of the quality of the papers.
Robinson et al (2006, 2007), rated ++, included one music therapy study in their review of the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia. The study (Groene, 1993) was included in two of the previous reviews (Vink et al and Sherratt et al). Robinson et al concluded that there is no evidence for the effectiveness of music therapy and that the identified evidence was assessed to be of low quality. This concurred with the conclusion made by Vink et al.
Similarly, Warner et al (2006), in their review of the effects of treatment on cognitive symptoms of dementia and the effects of treatments on behavioural and psychological symptoms of dementia, concluded that music therapy has unknown effectiveness. Their review, rated ++, identified two reviews and one subsequent randomised controlled trial. However, the conclusions are in part based on the evidence found in Vink et al review described previously (which is one of the reviews included here). The randomised controlled trial identified found that music based exercise improved cognition after three months compared with one to one conversation with a therapist but Warner et al pointed to methodological deficiencies in the trial including the possibility of allocation and assessment bias.
Watson and Green (2006) reviewed evidence for interventions to assist older people with dementia to feed. The review, rated +, identified four papers that included music. The intervention in all four studies was playing music at lunchtime. The authors report that all studies showed improvements in the outcomes measured but that statistical significance was seldom reported. However the results précis provided by Watson and Green showed only two studies that report changes in feeding, food intake or food helpings; and these appear inconclusive. Within the review the quality assessment criteria is not clear and the search terms are likely to have limited identification of relevant studies.
Another general review (Livingston et al, 2005; rated +) of psychological approaches to the management of neuropsychiatric symptoms of dementia identified 24 music or music therapy studies. The authors suggested that the studies show consistent evidence that music therapy decreases agitation during sessions and immediately after but that there is no evidence that music therapy is useful for treatment of neuropsychiatric symptoms in the longer term. Whilst overall it is a comprehensive review, it is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the randomised controlled trials, it is difficult to determine study design or details such as sample characteristics or setting.
Similarly a further general review (Cohen-Mansfield, 2001, rated -) that considered the impact of non-pharmacological interventions on inappropriate behaviours in dementia reported that all but one of the 11 studies identified reports either a significant reduction or positive trend in some inappropriate behaviours. The volume of studies included in the overall review (n=83) mean that some, but not all of the studies were described, but all were given equal weight. Whilst methodological issues were presented within the discussion section, these relate to diverse measurement methods, criteria for success, screening procedures, control procedures and treatment of failures; little or no account is taken of study design.
Summary
The papers that explored the use of music and music therapy formed the largest grouping within this review. The evidence presented leads to the conclusion that music and music therapy does work in reducing a number of behavioural and psychological symptoms problems. These include reducing agitation, aggression, wandering and restlessness, irritability and social and emotional difficulties and improving nutritional intake. However despite the large number of studies, the reviews did identify some methodological limitations (including weak study designs and small sample numbers) which mean that the evidence is not strong.
The evidence suggests the following:
• Playing preferred (favourite) music may reduce agitation
• Playing preferred music during bath time may reduce occurrences of aggressive behaviour
• Group music activities including listening, singing and playing compared may reduce wandering behaviour.
Physical Activity/Exercise
The beneficial effects of a physically active lifestyle in health promotion are well-documented (DH, 2004; WHO, 2004). Five systematic reviews evaluated the evidence of the effect of physical activity/exercise on mood, sleep, functional ability (activities of daily living), wandering, agitation and cognitive function for those with dementia (Eggermont & Scherder, 2006; Robinson et al, 2006, 2007; Livingston et al, 2005; Penrose, 2005; Cohen-Mansfield, 2001). The quality of the reviews varied from ++ rating to - rating. A summary of the key characteristic of the reviews are provided in table 11, p140-143. Hermans et al 2007, in their review of non-pharmacological interventions for wandering of people with dementia, also highlight the use of exercise and walking therapies that aim to prevent and/or reduce wandering but were unable to identify any studies in this area that fitted the review inclusion criteria.
Eggermont & Scherder (2006), rated ++, evaluated the effect of planned physical activity programmes on mood, sleep and functional activity in people with dementia. The review included 27 studies, six of which were randomised controlled trials. The randomised controlled trials included a daily seated exercise programme, exercise to music three times a week and daily 30 minute walks. Eggermont and Scherder found, taking the methodological quality of the studies and differences between interventions into consideration, that sustained walking in particular, may benefit affective behaviour (mood) and that physical activity appears to have a beneficial impact on the quality of sleep.
Based on their evaluation of the evidence they suggested that:
• Exercise programmes should include a walking activity and take at least 30 minutes in order to benefit mood;
• Exercise should be offered frequently during the week irrespective of duration, to achieve a positive impact on sleep;
• Care home residents need a long-term exercise programme with extensive sessions if a positive impact on their ADL is to be achieved (Eggermont & Scherder, 2006; p418).
Robinson et al (2006, 2007) in their review, again rated as ++, attempt to determine the effectiveness and acceptability of non-pharmacological interventions to reduce wandering dementia. The review identified one randomised controlled trial that compared a moderate intensity exercise programme (aerobic/endurance activities, strength training, balance and flexibility training) with usual care. The setting was an Alzheimer’s unit in Italy. The reviewers concluded that the study provided some evidence that moderate intensive exercise may reduce wandering.
Two of the remaining reviews cited inconclusive evidence. Livingston et al (2005), rated +, considered the effect of psychological approaches on neuropsychiatric symptoms. Two of the four studies identified in this review were randomised controlled trials that evaluated a walking/talking programme and a psychomotor activation programme respectively. Neither reported significant behavioural changes.
Penrose (2005), rated -, appraised the role of exercise, including aerobic and resistance training, in maintaining or improving the cognitive function of persons with Alzheimer’s disease. The review concluded that there was a lack of strong evidence of statistical significance to prescribe exercise/physical activity to maintain cognitive function or prevent cognitive decline in persons with Alzheimer’s disease. However, many of the studies reported within the review did not reflect the review question and it was unclear how many studies were included. The two randomised controlled trials reported both had small sample numbers (it is not clear whether more randomised controlled trials were identified).
The final review that included evidence of the impact of physical activity was Cohen-Mansfield (2001) and was assessed to be rated -. The review explores the impact of non-pharmacological interventions on inappropriate behaviours. Two studies within the review focussed on outdoor walks; the intervention for the first involved escorting residents to an outdoor garden (a one to one intervention); the second consisted of group walks through common areas or outside. The review reported decreases in inappropriate behaviour for both interventions (the former found a significant decrease in physically aggressive behaviours and non-aggressive behaviours; the latter a significant decrease in agitation). It is doubtful that the findings were statistically significant given the small sample numbers (n=12 and n=11 respectively). Two more physical activity studies were included in the review table, but the author made no comment with regard to their results.
Summary
The evidence suggests that physical exercise does work for behavioural and psychological symptoms and functional ability; evidence from the reviews was consistent with Eggermont and Scherder (2006):
• Sustained walking may benefit mood
• Physical activity appears to have a beneficial impact on the quality of sleep
• Whilst physical activity may have positive effects on functional ability in care home residents this is only when a long lasting exercise programme is applied
• Moderate intensive exercise may reduce wandering
Reality Orientation
Reality orientation aims to decrease confusion and dysfunctional behaviour patterns in people with dementia by orientating patients to time, place and person (Paton, 2006). Three reviews (Bates et al, 2004; Livingston et al, 2005; Verkaik et al, 2005), all rated +, included reality orientation studies in their paper. A summary of the key characteristic of the reviews are provided in table 12, p144.
Bates et al (2004), in their review, investigated the effectiveness of psychological interventions for people with milder dementia. Two studies were identified and the authors concluded that, taking the two studies together, there is evidence that reality orientation is an effective intervention in improving cognitive ability. However, neither study demonstrated that reality orientation is effective in improving well-being or improving communication, functional performance and cognitive ability. It is of note that the studies had small sample sizes and no power calculations which could overstate positive results.
Livingston et al (2005) explored psychological approaches to the management of neuropsychiatric symptoms of dementia. Their review identified 11 reality orientation studies and reported inconclusive evidence. Of the two randomised controlled included, one showed no immediate benefit compared with active ward orientation; whilst the other showed a non-significant improvement in behaviour when reminiscence therapy was preceded by reality orientation but not vice versa.
The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia was reviewed in Verkaik et al (2005). The review identified five studies, two randomised controlled trials and three case control studies. The quality of all five studies was assessed to be low. Only one study found significant improvement in depression; one further study reported improvement in apathy. The authors concluded that there were no or insufficient indications that the intervention reduces depressive, aggressive or apathetic behaviours in people with dementia.
Summary
Reality orientation might work but the evidence presented is inconclusive. The quality of the studies included in the reviews is, as acknowledged by the review authors, low. Again the studies were characterised by small sample numbers. Whilst there are positive results reported in respect of improvements in cognitive ability, depression and apathy the reviews agree that the evidence is inconclusive.
Reminiscence Therapy
Reminiscence therapy involves the discussion of past activities, events and experiences with another person or group of people, usually with the aid of tangible prompts such as photographs, household and other familiar items from the past, music and archive sound recordings (Woods et al, 2005, p1). Four reviews assessed reminiscence therapy studies in respect of cognitive symptoms, mood, behavioural and psychological symptoms, management of neuropsychiatric symptoms and depressed, aggressive and apathetic behaviours in people with dementia (Warner et al, 2006; Woods et al, 2005; Livingston et al, 2005; Verkaik et al, 2005). Key characteristics of the reviews are outlined in table 13, p145-146.
Warner et al (2006), in a review rated ++, explored the effects of treatment on cognitive behavioural and psychological symptoms of dementia. Within the review three studies are identified that assessed reminiscence therapy. These included one systematic review (Woods et al, 2005, discussed further below) that performed a meta-analysis and found reminiscence therapy improved cognition. The studies included in the analysis used diverse measures and were often small. Warner et al recommended that larger and better studies on reminiscence therapy are needed.
The Woods et al (2005) review was itself rated ++. Five randomised controlled trials were included in the review but data was extracted for only four of those studies for the meta-analysis. The inclusion criteria were such that the trials included could be either group or individual sessions involving photographs, music and videos of the past. The duration was set at a minimum of 4 weeks and 6 sessions and led by professional staff or by care-workers trained by professional staff. The interventions were either on an individual or group basis and the format of the sessions was diverse. For example, reminiscence facilitated by old photographs, books, magazines, newspapers and domestic articles or, in another study, by the development of a life story book.
The authors reported results of the analysis that were statistically significant for cognition (at follow-up), mood (at follow-up), and on a measure of general behavioural function (at end of intervention period). Improvement in cognition was evident in comparison with both no treatment and social contact conditions. However, of the four randomised controlled trials included, several were very small studies, or were of relatively low quality and, as indicated above, each examined different types of reminiscence work. They concluded that more and better designed trials are needed so more robust conclusions may be drawn.
Livingston et al (2005), in their review of psychological approaches to the management of neuropsychiatric symptoms of dementia, identified five reminiscence therapy studies. The review assigned a grade to the studies equivalent to troublingly inconsistent or inconclusive studies. Of the three randomised controlled trials included one found a non-significant improvement when reminiscence therapy was preceded by reality orientation but not vice versa; the other found no benefit. The review itself was rated as +, whilst being comprehensive it was let down by lack of detail in the search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (n=162), other than highlighting the randomised controlled trials it was difficult to determine study design or details such as sample characteristics or setting.
Another review rated as + (Verkaik et al, 2005) identified two reminiscence therapy studies within its review of the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia. One randomised controlled trial judged to be of low quality reported significantly lower self-reported depression at post-test. Whilst a case control study reports no changes in apathy.
Summary
In line with Woods et al, the reviews showed evidence that reminiscence therapy might work; that it has potential benefits in terms of cognition, mood and general behaviour. However these results are based on trials with small sample sizes and of relatively low quality. In addition there was variation in the type of reminiscence work reported. Thus whilst there is the potential for reminiscence therapy to be beneficial in all these areas evidence of their effectiveness is not robust. The study limitations highlighted by Woods et al need to be addressed.
Snoezelen/Multi-sensory Stimulation
Multi-sensory stimulation (MSS), also known as Snoezelen, is visual, auditory, tactile and olfactory stimulation offered to people in a specially designed room or environment (Baker et al, 2001). Six reviews explored the use of MSS in people with dementia. MSS was the sole focus of two reviews (Chung & Lai, 2002; Lancioni et al, 2002) whilst the remainder identified MSS studies in more general reviews (Robinson et al, 2006, 2007; Livingston et al, 2005; Verkaik et al 2005; Cohen-Mansfield, 2001). The effects on disruptive behaviour, mood, depression, aggression, apathy, cognition, social/emotional behaviours, wandering and neuropsychiatric symptoms were assessed. A summary of the key characteristic of the reviews are provided in table 14, p148-149.
Chung and Lai (2002), rated ++, assessed the efficacy of Snoezelen as a therapeutic intervention for older people with dementia. Including only randomised controlled trials the review identified three papers representing two trials. The first (Baker et al, 2001) compared Snoezelen to a one to one programme based on individuals’ preferences and abilities with no provision of obvious sensory inputs. The second was an extension of the first trial (Baker et al, 2003). The third paper, van Weert (2005) reported on the effect of Snoezelen on mood, behaviour and communication. The review combined the data from the latter two papers and found, in respect of behaviour, the results favoured the Snoezelen programme but there were no longer term treatment effects; no significant effects on mood were reported post intervention and no longer term effects on communication/interaction. Thus overall the review found no evidence for efficacy of Snoezelen for dementia. The review suggested there is a need for more reliable and sound research-based evidence to inform and justify the use of Snoezelen in dementia care.
Lancioni et al (2002) examined within-session, post-session and longer-term effects of Snoezelen with people with developmental disabilities and dementia. Whilst they identified 21 studies in the review, only seven related to dementia; none of those identified were included in the previous review (Chung & Lai, 2002). The review authors’ tentative conclusions
were that Snoezelen may have positive within-session effects on social/emotional behaviours. They went on to add that such positive effects could be increased by choosing appropriate stimuli for individual participants; and that increasing within-session positive effects may increase post-session effects. However, the review was only rated – for a number of reasons. The literature search was limited; only PSYCLIT and Medical Express databases are included in the computerised search and no details were given of the search terms used, numbers of papers initially retrieved, inclusion/exclusion criteria, or process followed. In addition there was only limited discussion of study methodologies; this was divorced from the results and did not provide strong guidance on the interpretation of results from individual studies. Overall the limitations may have resulted in effects being overstated.
Robinson et al (2006, 2007) in their general review that aims to determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering dementia, identified three MSS studies. All studies were randomised controlled trials. Baker et al (1998) compared Snoezelen to a one-to-one non-multi-sensory programme; Baker et al 2003 (described previously); and McNamara & Kempenaar (2001) who compared MSS with tactile stimulation. The review authors reported some evidence, albeit of poor quality, for the effectiveness of multi-sensory environment. Of the three randomised controlled trials; two did not provide evidence that a multi-sensory environment effectively prevents wandering; the third provided no follow up details and so the study yielded no information about effectiveness. The review was rated ++.
Another more general review, Livingston et al (2005), rated +, assessed psychological approaches to the management of neuropsychiatric symptoms. From the six papers identified in the review, the authors concluded that there was consistent evidence from non-randomised controlled trials that the effects from MSS are apparent for only a very short time after the session. Of the three randomised controlled trials one had no clear results; two found disruptive behaviour briefly improved outside the treatment setting but there was no effect after the treatment stopped. Overall the review was comprehensive but is let down by lack of detail in the search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (n=162), other than the randomised controlled trials, it was difficult to determine study design or details such as sample characteristics or setting of the studies reviewed.
Verkaik et al (2005) explored the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia. Within the three studies identified they concluded that there is some evidence (from two high quality randomised controlled trials) that MSS reduces apathy in people in the latter stages of dementia. Overall the review is rated + primarily because there was no discussion of the strength of evidence for no effect / negative effect; only positive effect.
The final review in this section is, again a more general review. Cohen-Mansfield (2001) carried out a review on the impact of non-pharmacological interventions on inappropriate behaviours. Of the four studies included the authors concluded that most report improvement though it is not necessarily statistically significant. The rating of – reflects that little or no account was taken of study design within assessment of the studies.
Summary
The evidence showed that MSS might work. The reviews reported positive results across a range of behaviours, including a reduction in apathy in people in the latter stages of dementia from two randomised controlled trials. Many of the improvements reported were not statistically significant and some results were conflicting. Overall the beneficial effects were not sustained and the reviews agreed that evidence was not robust due to small sample sizes and diverse measures of effectiveness.
Transcutaneous Electrical Nerve Stimulation (TENS)
One review, Cameron et al (2003) (rated as ++, see table 15, p150), sought to determine the effectiveness and safety of TENS (the application of an electric current through electrodes attached to the skin) in the treatment of dementia. Whilst TENS is typically used in pain relief, the review is based on studies by two groups (one in the Netherlands and one in Japan) that suggest TENS, applied to the back or head, may improve cognition and behaviour in those with dementia. Nine randomised controlled trials from the two groups were included in the review and three of those in the meta-analysis.
The authors reported that TENS produced a statistically significant improvement directly after treatment in delayed recall in one trial, face recognition in two trials and motivation in one trial. There was no effect on the other neuropsychological and behaviour measures either directly after or 6 weeks after treatment. They concluded that TENS may produce short term improvements in some neuropsychological or behavioural aspects of dementia. However, the limited presentation and availability of data from these studies does not allow definite conclusions on possible benefits. In respect of safety, although unlikely to have adverse effects, there is insufficient data to recommend its use.
Overall the review is both comprehensive and well designed. As the authors noted the studies included demonstrated consistency in experimental designs, subjects, interventions and outcome measures; but as only three could be used in the meta-analysis, generalisability of the findings to a wider population requires the work be replicated in a larger group of individuals.
Summary
The review shows that TENS might work but concludes that there is insufficient evidence to recommend its use. The current evidence, taken from randomised controlled studies within the review, shows potential benefits in the short term (directly after treatment) in recall, face recognition and motivation. Whilst the reviewed trials were well constructed there was insufficient data for the meta-analysis to, as noted by the authors, draw strong conclusions or to recommend its clinical use for those with dementia.
Validation Therapy
Validation is a method of communicating with and helping disoriented very old people built on an empathetic attitude and a holistic view of individuals[22]. The techniques of validation are simple to learn and can be performed within the course of a typical day[23]. Three reviews were identified that included assessments of validation therapy with people with dementia (Neal et al, 2003; Livingston et al, 2005; Verkaik et al, 2005). The reviews addressed management of neuropsychiatric symptoms, cognition, emotion, functional ability and depressed, aggressive and apathetic behaviours. A summary of the key characteristic of the reviews are provided in table 16, p151-152.
A review by Neal et al (2003), rated ++, assessed the efficacy of validation therapy, offered in group or individual format, as an intervention for patients with dementia or cognitive impairment. Three studies that met the review criteria and were assessed. All were randomised controlled trials. The first compared validation therapy, reality orientation and usual care (Peoples, 1982); the second validation therapy and usual care (Robb et al, 1986); and the last validation therapy, social care and usual care (Toseland et al, 1997). The results from the three studies were presented in terms of behaviour (two studies showed no statistically significant improvements in treatment effects, one study showed significant effect at 6 weeks); cognition (no statistically significant differences were reported); emotional state (no significant differences reported with the exception of depression at 12 months in one study); and activities of daily living (no statistically significant differences were reported). The review concluded there was insufficient evidence from randomised trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment.
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia (Livingston et al, 2005; rated +) assessed three validation therapy studies and concluded that there was no conclusive evidence. In this review there was only one randomised controlled trial (Toseland et al, 1997 included in previous review) comparing validation therapy to usual care or a social contact group. Toseland et al reported that no difference was found in independent outcome ratings, nursing time needed or in use of psychotropic medication and restraint.
The final review (Verkaik et al, 2005; rated +) considered the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia. This review included four validation therapy studies, two randomised controlled trials (again Toseland et al, 1997 was included) and two case control studies. Like the other reviews, the authors concluded that there was no or insufficient evidence; three studies found no significant changes in apathy, aggression or depression. The Toseland study, as reported previously, found significant change in depression after 1 year compared with alternate therapy but not the usual care group.
Summary
Whilst the evidence shows that validation therapy might work there is insufficient evidence that demonstrates the benefits of validation therapy. Potential benefits assessed in the reviews included the management of neuropsychiatric symptoms, cognition, emotion, functional ability, depression, aggression and apathy; but few studies reported improvements in any of these areas. The strength of evidence is, in part, hampered because there are few randomised controlled trials. Those trials that have been conducted are reported to have methodological issues that include lack of clarity in diagnosis of dementia, selection of outcome measures and the need for clarification about the precise nature of the intervention (Neal et al, 2003).
SECTION THREE
Introduction
The review in Section Two presented evidence of the effectiveness of non-drug interventions in alleviating the symptoms of people with dementia with the ultimate aim of helping people caring for individuals with dementia who want ideas about non-drug approaches for dementia that they might try or might access locally. The review found evidence that a range of interventions either do or might work to prevent or help cope with difficult behaviours or symptoms. This section of the report integrates these findings with suggestions and strategies identified from the website of four national/international dementia organisations to explore how some of the interventions identified in the review may be accessed or how they may be used or adapted for carers to try at home. In addition, where guidelines or recommendations have been made by the National Institute for Health and Clinical Excellence (NICE) and the Scottish Collegiate Guidelines Network (SIGN) these are presented. The matrices on pages 154-56 show the suggested strategies or interventions by dementia organisation, intervention type and behaviour/symptom. It is important to note that the majority of studies in the papers reviewed in Section Two related to dementia in a generic sense, rather than to one specific type of dementia and as such the recommendations made apply across all types of dementia.
The section is presented in two parts. The first presents strategies that carers might try by intervention type; the second by the behaviour or symptom it may be used to help prevent or cope with.
In line with the evidence in review the strategies presented attempt to address common behaviours and symptoms that people with dementia may present: aggression, agitation, anxiety, wandering, hallucinations, sleeplessness and depression. The root of many of these behaviours lies in confusion or frustration and the premise behind many of the suggestions included is to provide structure, stimulation (both mental and physical) and a calm environment to help prevent behavioural difficulties. Of the strategies outlined to help cope with difficult behaviours (behaviour and psychological symptoms of dementia) many are activities that provide a method of distraction from that behaviour. It is important to note that the suggested strategies are unlikely to work for everyone, nor is any one solution definitive – what works today may not work tomorrow[24]. In addition advice should always be sought from a doctor given that any changes in behaviour or symptoms may result from a physical illness, discomfort or psychiatric illness[25].
Interventions
Acupuncture
Acupuncture has been used to treat a number of conditions including musculoskeletal pain, headaches, muscles strain, arthritic pain, bowel problems, allergies, skin problems and in the management of withdrawal from addictive substances. The process involves fine needles being inserted through the skin and briefly left in position. The number of needles varies but may be only two or three[26]. Whilst acupuncture is one of the most popular forms of complementary therapies in the UK (Smallwood, 2005), no evidence was found to support its use for individuals with dementia and no recommendations were made for its use on the dementia organisations’ websites. If carers would like to explore the use of acupuncture accredited practitioners may be identified through one of the professional bodies in the field such as The British Medical Acupuncture Society () or The British Complementary Medicine Association ().
Animal Assisted Therapy
As outlined in Section Two, AAT typically involves interaction between a client and a trained animal, facilitated by a human handler, with a therapeutic goal such as providing relaxation or pleasure, or incorporating activities in physical therapy or rehabilitation (Filan & Llewellyn-Jones, 2006, p598). The therapy may simply involve the person with dementia focussing on an animal for a specified time (for example, grooming or stroking a dog) with the aim of prompting conversation (for example, about previous pets) or promoting or increasing physical activity over time [27].
Evidence from the review suggests that AAT might work to reduce aggression and agitation, improve social behaviour and nutrition. Whilst many of the studies included in the review looked at AAT in terms of a trained animal and therapist, others looked at the presence of a dog or cat in the home (both in a residential and private setting) either full time or for short periods of time to reduce agitation and/or aggression and promote social behaviour.
Those caring for people with dementia may like to consider use of AAT delivered by those with appropriate training. In their response to recent NICE guidelines[28], the Alzheimer Society notes that carers have reported excellent results using AAT for non-cognitive symptoms and behaviour. They go on to stress that the intervention must be tailored to individual needs[29]. The NICE guidelines also suggest the use of AAT for those with anxiety or depression.
Whilst carers might want to formally access AAT, pets are thought to be a source of comfort and relaxation for many people with dementia, creating a calming environment[30] that can contribute to the well-being of the person being cared (Wilson & Turner, 1998). Pets have also been shown to reduce depression and boost self-esteem[31]. Indeed it has been suggested that the presence of an animal can provide a sense of meaning, diversion and serendipity; that companion animals provide unconditional positive regard in stages of Alzheimer’s disease where normal avenues of communication fail (Baum & McCabe, 2003). Caregivers may also benefit as stroking or petting a dog or cat can help reduce stress (Baum & McCabe, 2003).
The following box illustrates strategies the caregiver might like to try. However, it should be noted that not everyone will react positively to animals and the benefits of pets can vary a lot by the individual[32]. The Alzheimer’s Association suggests those who owned pets previously tend to be more responsive and go on to say that the animal’s activity and energy level be matched with that of the individual; that a lively dog might be appropriate for someone who can go out for a walk whilst a cat may be more appropriate for a person who is less mobile[33].
Fish, and in particular the presence of a fish tank, may also have benefits. Within the review one paper reported a positive impact on nutritional intake when a fish tank was introduced in the dining room of a residential home and, in the same way the presence of a cat or dog may have a calming effect so too may the presence of fish in a tank.
• A calm unstressed environment can help avoid behaviours such aggression and agitation. Stroking a pet or petting for example, a cat or dog can have a calming and relaxing effect; similarly the presence of a fish tank may have a calming effect [34]
• Distraction is often useful when a person becomes agitated or aggressive. An activity such as stroking or grooming a pet can provide that distraction[35]
• When becoming confused, restless or insecure the person with dementia may be comforted by the presence of a pet[36]
• To stimulate conversation try stroking or grooming the pet together.
• Walking the dog together can provide exercise for both the person being cared for and the caregiver. Increased exercise can reduce the risk of depression. It can also provide an opportunity for enjoyment, pleasure and social contact[37].
Aromatherapy and Massage
Unlike in the previous section, in which aromatherapy and massage were presented separately, here they have been amalgamated due to considerable overlap.
Aromatherapy
Aromatherapy is the systematic use of essential oils in holistic treatments to improve physical and emotional well-being. Thus it is based on the theory that essential oils have healing powers[38]. The essential oils, extracted from plants, are applied in a variety of ways including directly to the skin through massage, by adding a few drops to baths or by inhalation (for example, heated in an oil burner)[39].
The review found evidence that aromatherapy might reduce agitation, neuropsychiatric symptoms and wandering. In line with NICE clinical guidelines, the evidence suggests that carers may consider use of aromatherapy for the person they care for. Within the studies reviewed aromatherapy was used in a variety of ways. These included the use of essentials oils with massage by a trained practitioner, essential oils in a diffuser in the air and drops of oils placed on bedding or to clothes. The majority of studies looked at use of lemon balm or lavender oil; indeed lavender is considered to be the safest oil to use[40].
Oils should be diluted according to the instructions before being applied to the skin[41] and used with caution. If used appropriately they are unlikely to cause side effects. Both NICE and the SIGN recommend that the use of aromatherapy be discussed with a qualified aromatherapist who can advise on contraindications.
Aromatherapy provides sensory stimulation. Sensory experiences are important in as much as those with dementia may have severe difficulties with reasoning and language, but they will still have their sense of taste, touch and smell[42]. Aromatherapy can be used as a relaxing or soothing strategy; as a technique to help prevent for example, aggression or agitation by adding a few drops of lavender oil to a bath[43] or giving a hand massage, again using a scented oil such as lavender[44].
While, as suggested earlier, advice should be taken over which oils are most appropriate to use (massage is discuss in more detail in later) carers might try introducing aromas into the home environment to facilitate a calm or soothing environment through, for example, fresh flowers or pot pourri. The sense of smell might also be stimulated through visits to garden centres or flower shows[45].
Massage and touch
Evidence from the review suggests that massage or touch therapies work in reducing agitation; that hand massage; music followed by hand massage or music and massage simultaneously each for 10 minutes can have an immediate effect and short term reduction in agitated behaviour; and that gentle touch on the forearm accompanying verbal encouragement can encourage eating.
As highlighted earlier, sensory experiences are important. NICE suggest that massage is delivered by someone with appropriate training and this may be something that carers seek advice from specialist practitioners on[46]. The person being cared for may enjoy hand, neck and foot massage[47], it may be used as a calming activity when a person is, for example, agitated or provide a distraction when confused or restless. Carers might want to contact practitioners of massage in order to learn appropriate massage techniques.
Whilst massage and massage techniques maybe useful, simple techniques that involve physical contact and touch are important and may be used to help the person being cared for, both in preventing unusual behaviour and as a coping strategy for the carer during those behaviours. These sensory techniques might involve simply touching or gently stroking a person’s hand, or brushing their hair. As the Alzheimer’s Society note, even when conversation becomes more difficult, being warm or affectionate can help carers to remain close to their loved ones, or for the person with dementia to feel supported. Communicate your care and affection by the tone of your voice and the touch of your hand. Don't underestimate the reassurance you can give by holding or patting the person's hand or putting your arm around them, if it feels right[48].
When a reaction occurs, for example, if the person being care for becomes agitated or aggressive one coping strategy may be to stay calm and gently hold their hand or to put your arm around them[49]. Similarly, in coping with hallucinations, touching and talking in a calm and reassuring way may bring the person back to reality[50] and gentle patting might distract the person’s attention and reduce the hallucination[51]. However, whilst touch can provide reassurance, be calming and provide a distraction it is advisable to try to avoid restraining or preventing someone with dementia from moving about when they are feeling agitated or nervous[52] and that the touch is not interpreted as a form of restraint.
In addition to the use of gentle touch for preventing or coping with unusual behaviour, depression may also respond to more one-to-one interaction, such as talking, hand holding, or gentle massage[53]. The following box highlights some techniques carers might like to try.
• A hand massage using scented oil can be very soothing. Try a hand massage using lavender or lemon balm ; music followed by a hand massage or music and a hand massage for 10 minutes to reduce agitation
• A calming environment may help to avoid difficult behaviours such as aggression or agitation. Try using different aromas: an oil burner infused with a few drops of scented oil, fresh flowers or pot pourri
• Try reducing difficult behaviours at bath time by adding few drops of scented oil in the bath
• Try stimulating sense of smell though visits to garden centres or flower shows
• In coping with unusual behaviours such as agitation offer reassurance, by touching and holding or try to distract the person, using a calming activity such as a hand massage[54] or brushing the person’s hair
• When becoming confused, restless or insecure the person with dementia may find a back rub calming[55]
• For those people being cared for who are depressed try more one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate[56].
• Where the person may do or say something over and over again (repetition) reassure them with a calm voice and gentle touch[57].
• Try a gentle touch on the forearm together with verbal encouragement to encourage eating
• If the person with dementia is experiencing a hallucination try touching and talking to the person in a calm and reassuring way – it might help bring the person back to reality[58]. Gentle patting might distract the person’s attention and reduce the hallucination[59].
• Try using essential oils in a diffuser in the air or drops of oils placed on bedding or to clothes to reduce wandering.
Behaviour Management
The interventions under the behaviour management umbrella in the review included social skills training, problem solving and behavioural reinforcement to address wandering, depression, aggression, apathy and neuropsychiatric symptoms. The review shows that behavioural management interventions might work in alleviating some symptoms of dementia. However evidence of their effectiveness in respect of reducing wandering, depression, aggression, apathy and neuropsychiatric symptoms is inconclusive.
As the review indicates carers may apply behaviour management techniques. The techniques are usually structured, systematically applied, time limited and, importantly, carried out under the supervision of a professional with expertise in the area[60]. Carers might consider accessing these techniques locally. Carers can also ask for an assessment of key factors that may improve challenging behaviour in those they are caring for. The NICE clinical guidelines are clear that that those with dementia who develop non-cognitive symptoms should be offered an assessment at the earliest opportunity that includes behavioural and functional analysis. As a result of this assessment an individually tailored care plan is formulated that can help carers.
SIGN (2006) note that behaviour management may be used to reduce depression in people with dementia. This recommendation is based in part on the randomised controlled trial included on the Varkaik (2005) review that showed those with Alzheimer’s living at home with depression are less depressed when their caregivers are trained in using behaviour therapy-pleasant events or behaviour therapy-problem solving.
Cognitive Stimulation Therapy /Cognitive Training
General cognitive stimulation involves a range of group activities and discussions aimed at enhancing cognitive and social functioning; similarly cognitive training involves guided practice on a set of standard tasks designed to reflect memory, attention, language or executive function (Clare and Woods 2004).
The review points to potential benefits from cognitive rehabilitation and training – that it might work for improving memory, cognitive functioning, neuropsychiatric symptoms, behaviour, depression, quality of life, learning, and activities of daily living. Whilst the evidence is inconclusive there are encouraging results for learning memory, executive functioning, activities of daily living, general cognitive problems, depression and self-rated general functioning (Sitzer et al, 2006).
Carers may wish to consider accessing locally cognitive stimulation programmes for those they care for. NICE guidelines state that people with mild to moderate dementia should have the opportunity to participate in a structured group cognitive stimulation programme commissioned or provided by health and social care staff with appropriate training and supervision. Similarly SIGN recommend that cognitive stimulation be offered to individuals with dementia.
Counselling
The review found no evidence that counselling works for improving recall, logic memory or learning for people with dementia. However, this statement should be tempered with the caveat that only one randomised controlled trial was identified within the review and this had a small sample size (Bates, 2004).
All the dementia organisations included in this part of the report referred to counselling and/or cognitive behaviour therapy in the treatment of depression for people with dementia. Carers might like to discuss the availability and appropriateness of these therapies with the doctor looking after the person with dementia. However, as Alzheimer Europe note, any kind of therapy which relies on verbal communication will only be suitable for a small number of people suffering from dementia or those in the early stages[61] .
For carers wishing to access counselling services accredited practitioners may be found through The British Association for Counselling and Psychotherapy ().
Environmental Manipulation (Including Lighting)
Making changes to, or manipulating, the environment has been posited to effect changes in neuropsychiatric symptoms and inappropriate behaviours including agitation. If stressful the environment can contribute to, or exacerbate, BPSD (behavioural and psychological symptoms of dementia). On the other hand, a supportive environment can alleviate BPSD (IPA, 2002, p3).
Within the review the environmental changes were diverse; they included the use of mirrors, sign-posting and access to outdoor areas. The absence of robust studies meant it was only possible to conclude that environmental manipulation might work for improving neuropsychiatric symptoms and decreasing agitation and wandering. Additionally, studies included in the review were based in residential or institutional settings and as such may not be easily transferable to a home setting.
This sub-section describes changes that could be made by carers in the home that might be useful in addressing behavioural and psychiatric symptoms of dementia. The suggestions include changes in lighting but it is important to note that these changes are not bright light therapy (which involves exposure to intense levels of light under controlled conditions[62]) as outlined in the review earlier in the report. The review concluded that the evidence for the use of bright light therapy was inconclusive. Whilst NICE makes no recommendations with regard to bright light therapy, SIGN state that it is not recommended for the treatment of cognitive impairment, sleep disturbance or agitation in people with dementia. Whilst carers might like to access bright light therapy no further suggestions are made within this report regarding its use other than to contact the health care practitioners involved in the care of the person with dementia to discuss availability and appropriateness. It is of interest however that the Alzheimer’s Society note that increasing light levels during the day might help with disrupted sleep[63]; whilst the Alzheimer’s Association recommend seeking morning sunlight exposure to improve sleep routines[64].
In order to help alleviate behaviours such as agitation, aggression or anxiety it is thought important to create a calming and relaxing environment. There are a number of different suggestions that carers may like to try. The over-riding principle of these strategies is to simplify the home environment in order to reduce confusion through changes in lighting, removal or relocation of mirrors or even creating a special place designed for relaxing. Whilst these visual elements are important so too are audio elements in the home which can trigger difficult behaviours or symptoms. Lower noise levels or removal of competing noises can also help create a calming environment by removing excess stimulation. In addition communication may be improved by avoiding competing noises such as television or radio[65].
One relatively easy strategy that carers may like to try is to look at the lighting in the home and consider whether it is adequate. Shadows, glare and reflections can be confusing or frightening for a person with dementia[66] and can even result in hallucinations, where the person with dementia can see things that do not exist for example, misinterpreting shadows as black holes[67]. Increased or adequate lighting can be used to eliminate shadows and may also help prevent sundowning (when people become more confused, restless or insecure late in the afternoon or early evening)[68].
Mirrors can also be a source of hallucinations; for example, if the person with dementia believes that he or she is seeing a strange face in the mirror. Try covering the mirror up or taking it down - it’s possible that the person doesn’t recognise his or own reflection[69]. This might be a useful strategy to take if bathing is difficult. Bathing can be seen by the person with dementia as threatening leading to screaming, resistance and even aggression. Whilst the behaviour may be due to physical discomfort it may be the reflection from a bathroom mirror leads to the belief that there is someone else in the room[70].
Sleeplessness may be a problem. Sleep is thought to be aided by use of nightlights in the bedroom. A radio playing softly may also help[71]; and if waking up during the night is a problem, nightlights may help the person with dementia recognise where they are when they wake up[72] providing reassurance and potentially reducing occurrences of shouting or screaming at night[73]. If wandering at night is a problem try placing nightlights throughout the home.
A further strategy that might be explored is creating a special place or room that is calming and relaxing, for example, by finding a calm place within the home to sit, reducing the noise and checking more often whether they need something[74]. If there is a spare room in the home try creating a calm and relaxing room for both the person with dementia and the person caring for them by adding a comfortable chair, music and plants or fresh flowers. This could be come a retreat for the person with dementia if they become agitated[75]. To reduce confusion try use of strong but calming colours; avoid pale colours which may be hard to see and very bright colours which may be over stimulating[76]. The following box summarises strategies the person caring for an individual with dementia can take.
• To help alleviate difficult behaviours including agitation, aggression and anxiety try creating a calming relaxing environment by:
• Removing competing noises such as radio or television
• Ensure lighting is adequate as shadows, glare and reflections can be confusing or frightening
• Mirrors can be a source of hallucination; consider taking them down,r covering them up or moving them
• Use nightlights to aid sleep and provide reassurance
• Furnish a special room or place for relaxing with calming items including for example, comfortable seating, calming music and plants or flowers
Music and Music Therapy
Even when other abilities are seriously affected people may still enjoy singing, dancing and listening to music[77]. The papers in the review that explore use of music and music therapy showed that music and music therapy does work in reducing a number of behavioural problems including agitation, aggression, wandering and restlessness, irritability and social and emotional difficulties and improving nutritional intake. The evidence suggests the following:
• Playing preferred (favourite) music may reduce agitation
• Playing preferred music during bath time may reduce occurrences of aggressive behaviour
• Group music activities including listening, singing and playing may reduce wandering behaviour.
People caring for a person with dementia might want to access music therapy and several organisations provide group (and individual) music activities. Details of activities available locally are accessible on websites such as may be available through local health care providers. If there is a particular time of day when the person being cared for becomes agitated try scheduling music therapy just before that time[78].
Within the home, those caring for people with dementia could try playing music as a method of relaxation, to reduce agitation or aggression or as a vehicle for communication. Music therapy typically involves playing music for up to 30 minutes in a quiet room with someone present for at least some of the time (to make sure the person with dementia is comfortable and happy with the level of sound)[79]. This could be tried at home. Carers could try joining the person being cared for in listening to the music making it a shared experience, an opportunity for both the carer and the person being cared for to relax [80] and chat. The music can provide a focus for conversation.
The Alzheimer’s Association suggest use of live music, tapes or CDs as radio programs, interrupted by commercial breaks, can cause confusion[81]. If using recorded music, finding the right music is important. People tend to relate best to music they were familiar with as a child or young adult[82]; or to a favourite song, or favourite genre of music. The music can be selected to create the mood wanted and can be linked with other reminiscence activities such as using photographs to help provoke memories that act as a prompt for conversation or to share memories. Alternatively, rather than just listening, music can be used to encourage singing or even dancing together. Movement such as clapping or dancing can add to the enjoyment[83]. Singing can have a significant calming effect on some people; Alzheimer’s Australia suggest singing favourite songs or soothing lullabies[84].
Alternatively, carers might try creating a calming environment in which music is the background rather than the focus. Try playing soft enjoyable background music, favourite or familiar songs or soothing music[85]. This may be used as a strategy to help the person with dementia eat; having a radio or background music playing can be comforting, particularly for those eating alone[86]. Similarly, for those who can become agitated whilst bathing try playing soothing music or singing together[87].
Repetition of the same or similar music is useful in as much as short term memory loss can ensure enjoyment of the same piece of music over and over again and provide reassurance[88]. However, it is important to avoid over stimulation, look for signs of irritation or agitation and be alert to the possibility that some music may have negative connotations or provoke negative responses, for example by evoking unhappy memories[89]. Similarly sensory overload can be minimised by eliminate competing noises. Try shutting windows and doors and turning off the television[90]. Music might also be used as sleep inducing strategy either by playing soothing music[91] or by having a radio playing softly[92]. The strategies described are outlined below:
• Music can be used as the focus of an activity to help prevent or reduce difficult behaviours such as agitation, anxiety or aggression and to promote conversation:
▪ Join the person with dementia in listening to music making it a shared, relaxing experience that can be enjoyed and talked about
▪ Play favourite or soothing music or sing during bath time to reduce occurrences of aggressive behaviour
▪ Try group music activities including listening, singing and playing to reduce wandering behaviour
▪ Use music to encourage singing, clapping or even dancing
• Music can be used in the background to help reduce or prevent difficult behaviours by creating a calming and relaxing environment
▪ Try using background music to aid eating. Having background music or a radio playing can be comforting, especially for those eating alone
▪ Try playing background music at bath time. Background music can help reduce agitation while bathing
▪ For those who have difficulties sleeping having a radio or soothing background music playing softly can aid sleep
• Choice of music:
▪ Play favourite music remembering that people tend to relate best to music they were familiar with when younger
▪ Be aware that radio, interrupted by commercial breaks can cause confusion
▪ Choose the music to create the mood you want
▪ Avoid over stimulation – look for signs of agitation or irritation
▪ Be alert for music that provokes unhappy memories
Physical Exercise/Activity
The beneficial effects of a physically active lifestyle in health promotion are well-documented (DH, 2004; WHO, 2004). The review evaluated the effect of physical activity/exercise on mood, sleep, functional ability (activities of daily living), wandering, agitation and cognitive function for those with dementia and the evidence suggests that physical exercise does work. These findings are echoed by NICE who recommend that exercise interventions are made available to those with dementia who have depression and anxiety. Similarly, SIGN suggest structured exercise can help maintain mobility.
Strategies for increasing the physical activity of those with dementia can be incorporated into the daily routine of both the person being cared for and the person undertaking the caring. As illustrated in the review the potential benefits are myriad. Regular exercise can prevent or reduce the symptoms associated with dementia by using up spare energy, acting as a distraction from difficult behaviours, providing a sociable activity and giving routine and structure to the day. As outlined earlier, physical activity can reduce the risk of depression[93], may help prevent outbursts of aggression[94], anxiety, and agitation and improve appetite and sleep. Physical exercise or activities can also provide a distraction from hallucinations[95] and can reduce wandering through alleviating boredom and using up spare energy[96].
The Alzheimer’s Society sums it up nicely:
Exercising together will help you and the person you care for. Exercise burns up the adrenalin produced by stress and frustration, and produces endorphins, which can promote feelings of happiness. This will help both of you relax and increase your sense of well-being. Exercise can help you develop a healthy appetite, enjoy increased energy levels and sleep better at night[97].
Physical activity or exercise can be introduced in a variety of ways to suit both the person with dementia and the person caring for them. The strategy used will be dependent availability and access to formal classes or a leisure centre and the ability, mobility and interests of the person with dementia. Financial costs will also play a part, although many of the suggested activities require little or no financial input. The individual suggestions are not mutually exclusive; an exercise programme can be achieved that incorporates a range of different activities and the variety will help reduce boredom. Advice on appropriate exercise and exercise programmes should be taken from the local doctor or health professional involved in the care of the person with dementia.
More formal activities that might be accessed for both the person being cared for and the carer include swimming which is a good all-round exercise, and can be very soothing and calming[98], dance classes or tai chi classes. Dance and tai chi provide not only a good source of physical activity but can be very sociable as well[99]. Often classes are tailored to older people and are designed to increase flexibility. Tai chi classes for frail older people have been found to be beneficial in preventing falls (Wolf et al, 2006).
Less formal recreation activities include walking. Walking is a good form of exercise providing a change of scenery and fresh air. Many carers find ways of arranging short walks, even if it is only a walk to the local shops[100], walking to places locally rather than driving or walking the dog together[101]. Walking can have a very calming effect on some people[102] and short walks can be incorporated into daily routines as a pleasurable activity that the person with dementia can enjoy[103].
Other good sources of physical activity are household tasks, which are a simple way to incorporate more exercise into everyday life. This may include outdoor activities like weeding, hosing, brushing up leaves or mowing the lawn; or household chores like washing up, folding washing, peeling vegetables or wiping the table[104]. Helping with household chores can provide the person with dementia with a sense of purpose and boost their self esteem; it can also add structure to the day and is a way to do something together with the carer[105].
Whichever strategy or combination of strategies are employed it is important to try to find an activity or task that the person with dementia will enjoy; to try to marry the physical exercise or activities with activities the person with dementia enjoyed before their illness, subject of course to the limitations inherent in their disease. In addition try to limit the activity to around twenty minutes and make sure they can accomplish the task. This will help prevent them become discourage or frustrated[106]. A summary of the suggested activities is provided in the following box.
• Regular exercise can prevent or reduce the symptoms associated with dementia using up spare energy, acting as a distraction from difficult behaviours, providing a sociable activity and giving routine and structure to the day
• Physical activity can reduce the risk of depression[107], may help prevent outbursts of aggression[108], anxiety, agitation and improve appetite and sleep. Physical exercise or activities can also provide a distraction from hallucinations[109] and can reduce wandering through alleviating boredom and using up spare energy[110].
• Take advice from your local GP on exercise and exercise programmes that you can access or do in the home
• Try swimming together
• Try accessing dance classes or tai chi classes locally
• Walking is a great form of exercise and may be incorporated into daily routine by walking to the local shops, walking short distances rather than driving or walking the dog together
• Household tasks are another method by which to incorporate physical activity. Outdoor tasks that the person with dementia may be able to help with include helping in the garden by for example, brushing up leaves, weeding or mowing the lawn. Within the home asks include the person with dementia helping with washing up, folding washing, peeling vegetables or wiping the table[111].
Reality Orientation
Reality orientation aims to decrease confusion and dysfunctional behaviour patterns in people with dementia by orientating patients to time, place and person (Paton, 2006). For example, by reminding the person with dementia where they are and what time it is. In addition, and in direct contrast to validation therapy, reality orientation also includes disagreeing with the person being cared for when they say something that is incorrect[112]. The review found that reality orientation might work, that there are positive results reported in respect of improvements in cognitive ability, depression and apathy but the evidence is inconclusive.
Whilst NICE make no recommendations with regard to reality orientation, SIGN suggest that it should be used by a skilled practitioner. Carers might contact the healthcare professionals involved in the care of the person with dementia to discuss access to and appropriateness of reality orientation.
Reminiscence Therapy
Reminiscence therapy involves the discussion of past activities, events and experiences with another person or group of people, usually with the aid of tangible prompts such as photographs, household and other familiar items from the past, music and archive sound recordings (Woods et al, 2005, p1). It involves stimulating recollection of events or memories and as such knowledge of the person is a prerequisite of individualised care[113].
The review showed evidence that reminiscence therapy might work; that it has potential benefits in terms of cognition, mood and general behaviour. NICE suggest that reminiscence therapy may be used for those with dementia and depression and/or dementia, whilst SIGN conclude there is a lack of clinical evidence on its effectiveness.
Whilst carers can explore the possibility of the person they care for formally accessing reminiscence therapy (through their local healthcare providers) there are a number of activities that can be carried out at home to aid reminiscing.
Activities can provide a means of distraction if the person being cared for is upset, agitated or anxious. An activity that includes props with which to reminisce provides such a distraction. People with dementia often remember the distant past more easily than recent events. If you can find a way to trigger the more distant, pleasant memories of the person you care for, they may become more lively and interested[114]. However, is should be noted that not all memories are pleasant and reminiscing can trigger unhappy memories. If the person being cared for does become upset try to give them the chance to express their feelings, and show them that you understand[115]. If their distress seems overwhelming then it might be better to switch to another form of activity[116].
The techniques carers can use to facilitate reminiscence can be very simple, for example looking through old photo albums together or listening a favourite piece of old music to more complex activities which require more preparation. A variety of reminiscence activities are presented in the following box.
• Talk about the past together, while looking at old family photos or books with pictures, or listening to old music[117].
• If reading skills have deteriorated make individual audiotapes[118].
• Locate picture books and magazines in the person’s areas of interest[119].
• Make a box of old objects that the person with dementia is interested in. Physically handling things may trigger memories more effectively than looking at pictures[120]
• Make a chronological history of the person with dementia together. It acts as a visual diary and can include photos, letters and postcards. Label the photos and limit the information on each page[121]
Snoezelen/Multi-sensory Stimulation
Multi-sensory stimulation (MSS), also known as Snoezelen, is visual, auditory, tactile and olfactory stimulation offered to people in a specially designed room or environment (Baker et al, 2001). Sensory stimulation is increased through use of lava and fibre optic lamps to provide changing visual stimulation, pleasant aromas, gentle music, and materials with interesting textures to touch and feel[122]. The evidence showed that MSS might work. The review reports positive results across a range of behaviours, including a reduction in apathy in people in the latter stages of dementia from two randomised controlled trials but overall the beneficial effects were not sustained.
Recommendations made by SIGN suggest that for those with moderate dementia who can tolerate it MSS may be useful but it is not recommended for neuropsychiatric symptoms in those with moderate to severe dementia. NICE recommend MSS for non-cognitive symptoms of dementia and for those with anxiety and/or depression.
Carers wishing to explore the use of MSS can contact the healthcare professionals involved in the care of the person with dementia to discuss the local availability and whether the intervention is appropriate for the person they care for.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS involves the application of an electric current through electrodes attached to the skin. Whilst TENS is typically used in pain relief it has been posited that TENS, applied to the back or head, may improve cognition and behaviour in those with dementia. The review shows that TENS might work but concludes that there is insufficient evidence to recommend its use.
For carers wishing to explore the use of TENS it is suggested that they contact the healthcare professionals involved in the care of the person with dementia to discuss the local availability and whether the intervention is appropriate for the person they care for.
Validation Therapy
Validation is a method of communicating with and helping disoriented people that is built on an empathetic attitude and a holistic view of individuals[123]. It is based on the premise that rather than trying to bring the person back to our reality it is more positive to enter their reality and that this in turn reduces their anxiety[124]. Thus, rather than correcting something you know isn't true, try to find ways around the situation rather than responding with a flat contradiction. If the person says 'We must leave now - Mother is waiting for me', you might reply, 'Your mother used to wait for you, didn't she?'[125] This means that the person with dementia is not made to feel foolish and their dignity and self esteem are maintained[126],[127]
It is suggested that the techniques of validation are simple to learn and can be performed within the course of a typical day[128]. The evidence from the review showed that validation therapy might work potentially benefiting the management of neuropsychiatric symptoms, cognition, emotion, functional ability, depression, aggression and apathy; but few studies reported improvements in any of these areas.
Whilst carers might approach their local health providers to find details of courses by which they can learn the techniques of validation therapy it has been suggested that elements of the approach are often employed by carers in their everyday life in as much as sometimes they don’t correct things they know are not true.
There are a number of strategies that carers might like to try. Given a focus on the emotional world of the person with dementia[129]; if a person appears to be living in the past, as the example of mother waiting illustrated, rather than correcting them try to relate to what they are remembering or feeling; encourage them to talk about the past.
Another common belief for people with dementia is that belongings have been stolen rather than misplaced. This may be indicative of feelings of insecurity or feeling threatened by the world. Thus if there is a there is a need to correct them make sure you do this sensitively, in a way that saves face and shows that you are not being critical[130]. For items that are frequently misplaced such as keys, the carer might wish to have duplicates available to assuage the anxiety and agitation of the person they care for. The misplaced item can be searched for later.
Failure to recognise objects can cause agitation or anxiety. Again validation suggests that rather than drawing attention to the mistake the carer provides help by explaining or demonstrating how it is used, but if the explanation is not accepted there is no point arguing[131].
If the person does not recognise someone or mixes up names you might try explaining who the person is but this explanation may be drawing unnecessary attention to the mistake. Again it may be better to ignore the mistake and listen to what they are trying to say[132]. Similarly in coping with wandering try not correcting the person when he or she says that they wants to leave to go to work or home[133].
The following box contains a précis of the strategies outlined above.
• If a person appears to be living in the past rather than correcting them try to relate to what they are remembering or feeling; encourage them to talk about the past.
• Misplaced beliefs may be related in insecurities or feeling threaten by the world; if there is a there is a need to correct them make sure you do this sensitively, in a way that saves face and shows that you are not being critical
• Failure to recognise objects can cause agitation or anxiety. Rather than drawing attention to the mistake provide help by explaining or demonstrating how it is used, but if your explanation is not accepted don’t argue
• Failure to recognise a person or mix up names can cause agitation or anxiety. Whilst you might try explaining who the people are it may be better to ignore the mistake and listen to what they are trying to say.
Symptoms or Behaviour
The review in Section Two identifies the evidence of what non-drug treatments work and what for. The symptoms or behaviours that are addressed (as presented in Matrix 1) ranged from the specific (agitation, anxiety) to the generic (behaviour, psychological symptoms). In this part of the report these symptoms or behaviours have been refined under key headings that emanate from both the review and the suggested strategies from the dementia organisations’ websites to present ideas about non-drug approaches for dementia that those caring for a person with dementia might try or might access locally. Under each heading is a description of the symptom or behaviour together with the suggested strategy for preventing or coping with it.
The dementia organisations all emphasise the importance of creating a calming and relaxing environment and of using activities to distract from difficult behaviours and relieve boredom which can be a trigger for some difficult behaviours. As such this section begins by providing a summary of general strategies for creating a calming environment and activities that the carer might like to try before going on to describe strategies to try for coping with or reducing the occurrences of particular difficult behaviours and symptoms.
Creating a Relaxing Environment
Creating a calming and relaxing environment may be achieved by minimising confusion through having a predictable routine and reducing clutter, noise and glare[134]. A summary of some strategies carers might like to try to facilitate such an environment is given below:
Change the physical environment by:
• Lower noise levels by shutting doors and windows and remove competing noises such as radio or television
• Ensure lighting is adequate as shadows, glare and reflections can be confusing or frightening.
• Similarly mirrors can be a source of hallucination; consider taking them down, covering them up or moving them
• Use nightlights to aid sleep and provide reassurance
• Furnish a special room or place for relaxing with calming items including for example, comfortable seating, calming music and plants or flowers
Use music:
• Having background music or a radio playing can be comforting and can aid sleep
• Choice of music:
• Play favourite music remembering that people tend to relate best to music they were familiar with when younger
• Be aware that radio, interrupted by commercial breaks can cause confusion
• Choose the music to create the mood you want
• Avoid over stimulation – look for signs of agitation or irritation
Use sensory stimulation
• Try using different aromas: an oil burner infused with a few drops of scented oil, fresh flowers or pot pourri or adding few drops of scented oil in the bath
• Try more one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate[135]
• Provide reassurance or encouragement talking with a calm voice and gentle touch[136]
• Touch is very important; try giving the person being cared for a hand massage[137], brushing the person’s hair or giving them a back rub
Carers might want to contact practitioners of massage in order to learn appropriate massage techniques. Courses in massage are often available within the local education centres. It is recommended that the use of aromatherapy be discussed with a qualified aromatherapist who can advise on the contraindications associated with different essential oils.
Pets
• The presence of a pet or the act of stroking or petting a pet for example, a cat or dog can have a calming and relaxing effect; similarly the presence of a fish tank may have a calming effect [138]
Activities
In some cases difficult behaviours can be headed off or coped with using an activity which provides a distraction from the behaviour or stops boredom. Carers might try using some of the activities described below.
Music Activities
• Music can be used as the focus of an activity:
▪ Join the person with dementia in listening to music making it a shared, relaxing experience that can be enjoyed and talked about
▪ Play favourite or soothing music or sing during bath time
▪ Try group music activities including listening, singing and playing
▪ Use music to encourage singing, clapping or even dancing
▪ Choice of music:
▪ Play favourite music remembering that people tend to relate best to music they were familiar with when younger
▪ Be aware that radio, interrupted by commercial breaks can cause confusion
▪ Try using music as the focus of an activity to help prompt happy memories and stimulate conversation but be alert for music that provokes unhappy memories
▪ Choose the music to create the mood you want
▪ Avoid over stimulation – look for signs of agitation or irritation
Pets
• An activity such as stroking or grooming a pet can provide that distraction[139]; try getting the person with dementia to stroke or groom the pet or do it together
• Walking the dog together can provide exercise for both the person being cared for and the caregiver. It can also provide an opportunity for enjoyment, pleasure and social contact[140].
Sensory stimulation
• Touch is very important:
▪ Try using a hand massage[141], brushing the person’s hair or giving them a back rub
▪ Try more one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate[142].
▪ Gentle patting might distract the person’s attention
Carers might want to contact practitioners of massage in order to learn appropriate massage techniques. Courses in massage are often available within the local education centres. It is recommended that the use of aromatherapy be discussed with a qualified aromatherapist who can advise on the contraindications associated with different essential oils.
Physical activity/exercise
• Regular exercise or physical activity can help use up spare energy, and provide a sociable activity giving routine and structure to the day.
▪ Try swimming together or accessing dance classes or tai chi classes locally
▪ Walking is a great form of exercise and may be incorporated into daily routine by walking to the local shops, walking short distances rather than driving or walking the dog together
▪ Household tasks are another method by which to incorporate physical activity. Outdoor tasks that the person with dementia may be able to help with include helping in the garden by for example, brushing up leaves, weeding or mowing the lawn. Within the home asks include the person with dementia helping with washing up, folding washing, peeling vegetables or wiping the table[143].
Reminiscing
• Try an activity that includes props with which to reminisce:
▪ Talk about the past together, while looking at old family photos or books with pictures, or listen to old music[144].
▪ If reading skills have deteriorated make individual audiotapes[145]
▪ Locate picture books and magazines in the person’s areas of interest[146]
▪ Make a box of old objects that the person with dementia is interested in. Physically handling things may trigger memories more effectively than looking at pictures[147]
▪ Make a chronological history of the person with dementia together. It acts as a visual diary and can include photos, letters and postcards. Label the photos and limit the information on each page[148]
Aggression
Aggression may manifest itself either verbally (shouting, name-calling) or physically (hitting, pushing) and can occur very suddenly[149]. It may be caused by hallucinations[150], anxiety, fear, agitation, nervousness, anger and frustration[151] or by low levels of physical activity[152]. It is important that the carer is mindful of their own safety at these times and whilst the strategies below may help to reduce the occurrences of aggression or cope with them when they happen it is recommended that if they don’t work that the carer leaves the room giving the person with dementia time and space to calm down[153].
Accessing interventions:
• Carers might consider accessing training courses for behaviour management techniques locally through their health care providers. Carers can also ask for an assessment of key factors that may improve challenging behaviour in those they are caring for. The NICE clinical guidelines are clear that that people with dementia who develop non-cognitive symptoms should be offered an assessment at the earliest opportunity that includes behavioural and functional analysis. As a result of this assessment an individually tailored care plan is formulated that can help carers.
• Consider use of AAT delivered those with appropriate training. Seek advice on local availability, access and appropriateness from your local health care provider
• People caring for a person with dementia might want to access music therapy and several organisations provide group (and individual) music activities. Details of activities available locally are accessible on websites such as may be available through local health care providers. If there is a particular time of day when the person being cared for becomes agitated try scheduling music therapy just before that time[154].
• Carers wishing to explore the use of MSS can contact the healthcare professionals involved in the care of the person with dementia to discuss the local availability and whether the intervention is appropriate for the person they care for.
• Carers might approach their local health providers to find details of courses by which they can learn the techniques of validation therapy
Things to try at home:
A calm unstressed environment can help avoid occurrences of aggression and carers might wish to try the strategies previously described to help create a calming and relaxing environment. In addition it may be possible to distract from the aggressive behaviour using the activities described earlier. If the person being cared for becomes aggressive stay calm and gently hold their hand or to put your arm around them[155]. Take care that the touch is not interpreted as a form of restraint. Strategies that are thought particularly useful in preventing or coping with aggression are presented below:
• To help reduce incidence of aggression try creating a calming relaxing environment by removing competing noises such as radio or television
• Regular exercise or physical activity can prevent or reduce aggressive behaviour[156] using up spare energy, acting as a distraction from difficult behaviours, providing a sociable activity and giving routine and structure to the day (see activities subsection)
• Bathing can be seen by the person with dementia as threatening leading to screaming, resistance or even aggression. The behaviour may be due the reflection from a bathroom mirror leads to the belief that there is someone else in the room[157]. Consider taking the mirror down, covering it up or moving it
• Aromatherapy can be used as a relaxing or soothing strategy as a technique to help prevent aggression by adding a few drops of lavender oil to a bath[158] as can playing soothing background music
Agitation or Anxiety
People with dementia may become anxious or agitated. Anxiety or agitation can manifest itself in pacing or constant fiddling, repetition of words or phrases and screaming[159]. Causes include lack of sleep or disruptive sleep patterns, physical discomfort, medication, and hallucination[160]
Accessing interventions
• Those caring for people with dementia may like to consider use of AAT delivered those with appropriate training for anxiety or agitation.
• People caring for a person with dementia might want to access music therapy and several organisations provide group (and individual) music activities. Details of activities available locally are accessible on websites such as may be available through local health care providers.
• Carers might like to access practitioners of bright light therapy which it has been suggested can help reduce agitation. Contact the health care practitioners involved in the care of the person with dementia to discuss availability and appropriateness of this type of therapy.
• Whilst carers might want to explore the possibility of the person they care for formally accessing reminiscence therapy (through their local healthcare providers) there are a number of activities that can be carried out at home to aid reminiscing. These are detailed below
• Similarly whilst carers might approach their local health providers to find details of courses by which they can learn the techniques of validation therapy, a number of validation techniques are detailed below
Things to try at home
Again, a calm and relaxing environment can help reduce the occurrences of agitated or anxious behaviour and carers might like to try some of the strategies presented earlier. Coping strategies for agitation or anxiety include distracting the person with dementia with activities that may also relieve or reduce boredom. Once again carers might like to try some of the activities detailed earlier. Strategies highlighted for agitation or anxiety include:
• An activity such as stroking or grooming a pet can provide that distraction from agitation[161]
• Try using different aromas: an oil burner infused with a few drops of scented oil, fresh flowers or pot pourri to prevent agitation
• Help prevent agitation by adding a few drops of lavender oil to a bath[162]
• A hand massage using scented oil can be very soothing. Try a hand massage using lavender or lemon balm ; music followed by a hand massage or music and a hand massage for 10 minutes to reduce agitation
• In coping with agitation offer reassurance, by touching and holding or try to distract the person, using a calming activity such as a hand massage[163] or brushing the person’s hair
• Playing favourite music may reduce agitation (see activities sub section)
• Music can be used as the focus of an activity to help prevent or reduce agitation or anxiety (see activities sub section)
• Try playing background music at bath time. Background music can help reduce agitation while bathing (see creating a calm environment sub section)
• Regular exercise can prevent or reduce occurrences of agitation or anxiety by using up spare energy, acting as a distraction, providing a sociable activity and giving routine and structure to the day (see activities sub section)
• Physical activity may help prevent anxiety and agitation and can also provide a distraction from hallucinations[164]. (see activities sub section)
• Validation techniques are another strategy by which to cope with or reduce anxiety or agitation:
▪ If a person appears to be living in the past rather than correcting them try to relate to what they are remembering or feeling; encourage them to talk about the past.
▪ Misplaced beliefs may be related in insecurities or feeling threaten by the world; if there is a there is a need to correct them make sure you do this sensitively, in a way that saves face and shows that you are not being critical
▪ Failure to recognise objects can cause agitation or anxiety. Rather than drawing attention to the mistake provide help by explaining or demonstrating how it is used, but if your explanation is not accepted don’t argue
▪ Failure to recognise a person or mix up names can cause agitation or anxiety. Whilst you might try explaining who the people are it may be better to ignore the mistake and listen to what they are trying to say.
Depression
Symptoms of depression are characterised by many of the behaviours referred to in this section, including increased agitation, aggression and sleep disturbance and readers should also refer to these subsections. Other symptoms might include social isolation or withdrawal, fatigue, loss of energy and feelings of worthlessness or hopelessness[165]. The first port of call for carers should always be the doctor. Whilst medication is often used to treat depression there are psychotherapies that carers might like to consider as well as other strategies that they may try at home to help alleviate some of the symptoms.
Accessing services
• Carers might like to discuss the availability and appropriateness of counselling or cognitive behavioural therapy with the doctor looking after the person with dementia.
• Those caring for people with dementia may like to consider use of AAT delivered those with appropriate training.
• People caring for a person with dementia might want to access music therapy and several organisations provide group (and individual) music activities. Details of activities available locally are accessible on websites such as may be available through local health care providers.
• Whilst carers might want to explore the possibility of the person they care for formally accessing reminiscence therapy (through their local healthcare providers) there are a number of activities that can be carried out at home to aid reminiscing (see subsection on activities).
• Similarly whilst carers might approach their local health providers to find details of courses by which they can learn the techniques of validation therapy, a number of validation techniques are detailed below
• Carers wishing to explore the use of MSS can contact the healthcare professionals involved in the care of the person with dementia to discuss the local availability and whether the intervention is appropriate for the person they care for.
• Carers might consider accessing training courses for behaviour management techniques locally through their health care providers. Carers can also ask for an assessment of key factors that may improve challenging behaviour in those they are caring for. The NICE clinical guidelines are clear that that people with dementia who develop non-cognitive symptoms should be offered an assessment at the earliest opportunity that includes behavioural and functional analysis. As a result of this assessment an individually tailored care plan is formulated that can help carers.
• Carers may wish to consider accessing locally cognitive stimulation programmes for those they care for. NICE guidelines state that people with mild to moderate dementia should have the opportunity to participate in a structured group cognitive stimulation programme commissioned or provided by health and social care staff with appropriate training and supervision. Similarly SIGN recommend that cognitive stimulation be offered to individuals with dementia.
• Carers might contact the healthcare professionals involved in the care of the person with dementia to discuss access to and appropriateness of reality orientation
Things to try at home
Distraction and avoiding boredom through activities are again strategies which might help as is creating a calming and relaxing environment. Readers should refer to these subsections. Particular strategies that are highlighted for depression are detailed below
• Increased exercise can reduce the risk of depression. It can also provide an opportunity for enjoyment, pleasure and social contact[166] (refer to activities subsection).
• Make sure that a small amount of time is spent in the sun each day[167]
• Try more one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate[168].
• Try validation techniques:
▪ If a person appears to be living in the past rather than correcting them try to relate to what they are remembering or feeling; encourage them to talk about the past.
▪ Misplaced beliefs may be related in insecurities or feeling threaten by the world; if there is a there is a need to correct them make sure it is done sensitively, in a way that saves face and shows that you are not being critical
▪ If the person being cared for fails to recognise rather than drawing attention to the mistake, provide help by explaining or demonstrating how it is used, but if your explanation is not accepted don’t argue
▪ If the person being cared for fails to recognise a person or mix up names. Whilst you might try explaining who the people are it may be better to ignore the mistake and listen to what they are trying to say.
Hallucinations
A hallucination is a false perception of objects or events, and is sensory in nature – seen, heard, smelt, tasted or even felt[169]. Techniques that may be used to cope with a person experiencing hallucinations include validation, reassurance, distraction through activities and modification of the environment (see the activities and creating a calming and relaxing environment subsection for the latter two).
Accessing interventions
• Carers might want to access music therapy and several organisations provide group (and individual) music activities. Details of activities available locally are accessible on websites such as may be available through local health care providers.
• Whilst carers might want to explore the possibility of the person they care for formally accessing reminiscence therapy (through their local healthcare providers) there are a number of activities that can be carried out at home to aid reminiscing (detailed in the activities subsection)
• Carers might approach their local health providers to find details of courses by which they can learn the techniques of validation therapy. In addition validation techniques to try at home are detailed below
Things to try at home
Strategies thought to be of particular help in reducing the occurrence or prevention or hallucinations are present below:
• Offer reassurance, by touching and holding or try to distract the person, using a calming activity such as a hand massage[170] or brushing the person’s hair. Carers might want to contact practitioners of massage in order to learn appropriate massage techniques. Courses in massage are often available within the local education centres. If using essential oils discussion with a qualified aromatherapist who can advise on the contraindications is recommended.
• Try touching and talking to the person in a calm and reassuring way – it might help bring the person back to reality[171].
• Gentle patting might distract the person’s attention and reduce the hallucination[172].
• Ensure lighting is adequate as shadows, glare and reflections can be confusing or frightening
• Mirrors can be a source of hallucination; consider taking them down or covering them up
• Try validation techniques:
▪ If a person appears to be living in the past rather than correcting them try to relate to what they are remembering or feeling; encourage them to talk about the past.
▪ Misplaced beliefs may be related in insecurities or feeling threaten by the world; if there is a there is a need to correct them make sure it is done sensitively, in a way that saves face and shows that you are not being critical
▪ If the person being cared for fails to recognise rather than drawing attention to the mistake, provide help by explaining or demonstrating how it is used, but if your explanation is not accepted don’t argue
▪ If the person being cared for fails to recognise a person or mix up names. Whilst you might try explaining who the people are it may be better to ignore the mistake and listen to what they are trying to say
Sleeplessness
Sleeplessness can be caused by a number of different factors including sleeping through the day due to boredom or inactivity, or simply due to insufficient energy expenditure. Again refer to the subsections dealing with activities and creating a calm environment for general strategies .
Accessing interventions:
• Carers might like to access practitioners of bright light therapy which it has been suggested can help reduce sleeplessness. Contact the health care practitioners involved in the care of the person with dementia to discuss availability and appropriateness of this type of therapy.
Things to try at home:
• Use nightlights to aid sleep and provide reassurance if awake
• Music can be used as sleep inducing strategy either by playing soothing music[173] or by having a radio playing softly
• Boredom can be addressed using a range of activities (see activities subsection)
Excess energy and boredom may be addressed by increasing physical activity (see activities subsection).
Wandering
Wandering may be due to a variety of cause including a changed environment, a loss of memory, excess energy, boredom, confusion of day with night, agitation, or discomfort or pain[174]. It may be the result of stress or anxiety or the side effects of medication[175] Agitation and anxiety are dealt with in a separate subsection and the reader should consult suggestions in those sections along with the suggested techniques described here.
Accessing interventions:
• Carers might consider accessing training courses for behaviour management techniques locally through their health care providers. Carers can also ask for an assessment of key factors that may improve challenging behaviour in those they are caring for. The NICE clinical guidelines are clear that that people with dementia who develop non-cognitive symptoms should be offered an assessment at the earliest opportunity that includes behavioural and functional analysis. As a result of this assessment an individually tailored care plan is formulated that can help carers.
• People caring for a person with dementia might want to access music therapy and several organisations provide group (and individual) music activities. Details of activities available locally are accessible on websites such as may be available through local health care providers. If there is a particular time of day when the person being cared for becomes agitated try scheduling music therapy just before that time[176].
• Carers wishing to explore the use of MSS can contact the healthcare professionals involved in the care of the person with dementia to discuss the local availability and whether the intervention is appropriate for the person they care for.
Things to try at home
The subsection on activities addresses strategies to alleviate boredom and cope with excess energy whilst, similarly the creating a calming and relaxing environment provides more general strategies.
• Try using essential oils in a diffuser in the air or drops of oils placed on bedding or to clothes. It is recommended that the use of aromatherapy be discussed with a qualified aromatherapist who can advise on the contraindications associated with different essential oils.
• For night time wandering use nightlights to aid sleep and provide reassurance
• For night time wandering music might be used as sleep inducing strategy either by playing soothing music[177] or by having a radio playing softly.
SECTION FOUR
Conclusions and Implications for Carers
The aim of this report is to help informal carers who want ideas about non-drug approaches for dementia, that they might try or that they could try to access. The first part of the report focused on three questions.
• What non-drug treatments work and what do they work for?
The evidence presented in the systematic review suggests three different interventions are effective for people with dementia. Music or music therapy, hand massage or gentle touch and physical activity or exercise. However even for these interventions the evidence is mixed or limited. For example, within the papers exploring music or music therapy methodological limitations were highlighted that included weak study designs and small sample numbers. Similarly evidence was presented for the use of massage or touch therapies and whilst there is evidence to suggest massage or touch therapies do work in a reducing agitation in the short term and can help with eating there was no conclusive evidence that massage reduces wandering, anxiety or aggressiveness.
The evidence from the review dovetailed with the information given by the dementia organisations. All the dementia organisations suggested strategies that include music, physical activity or exercise and touch or massage.
• What non-drug treatments might work and what for?
The majority of interventions fell into the ‘might work’ category due to inconclusive results (AAT, Aromatherapy, Behaviour Management, Cognitive Stimulation, Environmental Manipulation, Light Therapy, Reality Orientation, Reminiscence Therapy, MSS, TENS, Validation Therapy). The lack of firm evidence arose for a number of reasons including conflicting results and weakness in study design. The implication for carers is that whilst some of these interventions might be useful in managing symptoms of dementia the evidence is not strong enough to support their use. However, some of the interventions in this group formed the backbone of the suggested coping/prevention strategies included in the dementia organisations’ websites. This can be illustrated using reminiscence therapy. Reminiscence therapy involves discussion of past activities, events and experiences. The evidence showed that this type of therapy has potential benefits in terms of cognition, mood and general behaviour but the evidence rests on trials with small sample sizes and of relatively low quality and there was variation in the type of reminiscence work reported. The suggestions included in the dementia organisations’ websites such as talking over past events, looking through old photos or listening to old music all replicate the activities that form the essence of reminiscence therapy. The reasons for using these activities whilst worded more pragmatically did echo those of the review. The websites often didn’t mention ‘reminiscence therapy’ per se but rather recommended that these might be enjoyable activities (improve mood), that they might provide a distraction from difficult behaviours (general behaviour) or be a way of relaxing or stimulating conversation (cognition).
• What non-drug treatments do not work?
There was no evidence to suggest beneficial effects for only two interventions, acupuncture and counselling. Only one paper was found that attempted to explore the use of acupuncture (Peng et al, 2007) but unfortunately no studies met their criteria. This is particularly interesting given that acupuncture is one of the most popular complementary therapies in the UK (Smallwood, 2005). However, in line with the paucity of evidence for its use for people with dementia none of the dementia organisations suggested its use.
Counselling was included in one paper which reviewed psychosocial interventions for people with milder dementing illness (Bates et al, 2004). The review identified just one randomised controlled trial and reported that counselling provided an opportunity for the client to vent their concerns and receive validated information about their mental status; but the effectiveness of individual counselling sessions was not demonstrated on the outcome measures used (recall, logical memory, learning). Whilst no evidence was included for recall logic, memory and learning, all the dementia organisations included in this part of the report referred to counselling and/or cognitive behaviour therapy in the treatment of depression for people with dementia. Although Alzheimer Europe note, any kind of therapy which relies on verbal communication will only be suitable for a small number of people suffering from dementia or those in the early stages[178]
• What strategies might carers try?
The suggestions included in this report draw on research evidence and more pragmatic suggestions that appear have their roots in one or more of the interventions identified in the systematic review. The suggestions and advice presented within the dementia organisations websites appear to be based on both evidence from the literature and from suggestions made by carers themselves of strategies that had worked for them. Whilst some of the tips or suggestions made within the dementia websites did not mention a specific intervention or a theoretical premise it was clear that often the practical strategies were grounded in a specific intervention or that there were parallels between them. An example of this is the advice given not to correct misplaced beliefs which clearly has parallels in validation therapy.
It is important to note that the focus of these suggestions lies in behaviour and psychological symptoms. This is unsurprising given that virtually all patients with dementia will develop changes in behaviour as the disease progresses (Rayner et al, 2006, p647). Whilst the suggested strategies appear to be general, rather than specific across many behaviours consensus opinion is that the incidence of distress whether manifest in aggression, anxiety or sleeplessness can be ameliorated by a calming environment, structured activities and redirection or distraction (Lavretsky and Nguyen, 2006). The dementia organisations present a far more holistic picture than the evidence presented in the review. Whilst the focus of individual evaluations in the papers included in the review tended to be a single intervention all the dementia organisations emphasised the importance of a calming and relaxing environment with structure and routine (and how interventions and activities can help achieve this). This could have been anticipated given the nature of the research process and the complexity of evaluating multiple interventions.
A caveat in taking forward the strategies described here is to highlight that the focus of this report has been on coping or preventative strategies. The reported has alluded to triggers for these behaviours but it is important to emphasise that the strategies carers can try will be better informed by insight into the likely causes of that behaviour or symptom. Triggers can be a result of illness, the side effects of medication or physical discomfort. Changed behaviours or symptoms should be discussed with the health care professionals involved in the care of the person with dementia to eliminate these possibilities.
Implications for Future Research
As highlighted earlier, overall the studies included in the reviews were characterised by weak study designs and small sample sizes. Indeed three reviews were unable to identify any studies of sufficient quality to assess (the study inclusion criteria for Hermans et al (2007) and Peng et al (2007) included only randomised controlled trials; Price et al (2001) also included controlled trials and interrupted time series).
Many of the reviews included single person case studies or studies of less than five people. Whilst it is not possible to generalise about the effectiveness of different interventions many pointed to potential benefits from the intervention being assessed. The randomised controlled studies included in the reviews were of mixed quality and the meta-analyses were often limited by the small number of studies, and thus data, included.
Another area of concern was the range of the interventions under each ‘category’ which hampered analyses. For example, Sitzer et al (2006) carried out a meta-analysis of cognitive training that produced encouraging results but the interventions included in the analysis, under the umbrella of cognitive training, were diverse and the review did not point to the effectiveness of any one type of cognitive training. Measurement of outcomes was also highlighted as an area of concern by some reviews who pointed to the need for consistency in how outcomes are measured and use of validated outcome measures.
Many of the studies included were based in community residential settings (for example, in nursing homes). Given the increasing number of people now caring for people with dementia in their own home there is a clear need to ensure that research is transferable to this setting. Indeed, the IPA note that further research is need to explore the relationship of behavioural and psychological symptoms of dementia to the environments in which they occur (IPA, 2002, p7).
Taken together, whilst the volume of studies in this area is encouraging the review points to the need for large, well designed, randomised controlled studies rather than the seemingly piecemeal approach taken at present.
Implications for Service Providers and Commissioners
Of the 16 interventions identified, evidence exists for the benefits of three interventions for people with dementia: physical activity, music or music therapy and massage or gentle touch. The evidence is inconclusive for a further eleven. Whilst, as described earlier, carers can apply some of these interventions in the home setting at little or no cost to health or social care services (for example, playing favourite music), others are likely to require training (for example in hand massage) or instruction (for example, in appropriate exercise routines). In addition both service providers and commissioners should explore current and future provision of more structured group activities for people with dementia in line with the evidence presented; in particular the provision of group music therapy and group exercise activities that meet the needs of both the person with dementia and their carer.
Matrix 1a. Interventions and Symptoms Evidence Assessment: 0=Evidence of effectiveness; 1= No evidence of effectiveness; 2=inconclusive evidence
| |Aggression |Agitation |Anxiety |Apathy |Behaviour |Cognitive |Communi-cation |Depression |
| | | | | | |Function | | |
|Peng 2007 |++ |What is the efficacy |Search carried |Acupunct* |Specialised Register |0 |There is currently no evidence |Clear search criteria |
| | |and possible adverse |out February | |contained records from : | |available from sufficiently | |
| | |effects of acupuncture |2007. No | |CENTRAL, MEDLINE, EMBASE, | |high quality RCTs to allow | |
| | |therapy for treating |details of date| |PsycINFO, CINAHL, SIGLE, | |assessment of the efficacy of | |
| | |vascular dementia? |restrictions | |LILACS, ISTP, INSIDE, plus | |acupuncture in the treatment of| |
| | | | | |these, on-going trials | |vascular dementia | |
Table 2a . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched|No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Filan 2006 |+ |To review studies that |1960-2005 |Animal assisted |MEDLINE, |11 |AAT appears to offer promise as a |No details of how many studies were |
| | |have investigated whether | |therapy, pet and |PsychInfo, CINAHL | |psychosocial intervention for people |identified originally or screening |
| | |AAT has a measurable | |dementia | | |with dementia. The optimal frequencies |criteria |
| | |beneficial effect for | | | | |and duration of AAT sessions, as well |Some aspects of study design not clear –|
| | |people with dementia and | | | | |as the optimal format of such sessions,|for example randomisation; small sample |
| | |specifically upon | | | | |need systematic study. |sizes, selection criteria is likely to |
| | |behavioural and | | | | | |overestimate results |
| | |psychological symptoms of | | | | |Studies considered a number of | |
| | |dementia | | | | |interventions including ‘pet visits’, | |
| | | | | | | |introduction of a resident dog and | |
| | | | | | | |introduction of aquaria. Results were | |
| | | | | | | |reported in terms of: | |
| | | | | | | |reducing agitation and/or aggression; | |
| | | | | | | |promoting social behaviour; | |
| | | | | | | |improving nutrition | |
| | | | | | | | | |
| | | | | | | |The authors point to several | |
| | | | | | | |limitations in the studies reviewed; | |
| | | | | | | |these include potential bias | |
| | | | | | | |(participants have a prior history of | |
| | | | | | | |positive interaction with animals), | |
| | | | | | | |small sample sizes, unit of | |
| | | | | | | |randomisation, duration of impact | |
| | | | | | | |unclear | |
Table 2b . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT). General Review Including AAT
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched|No of AAT |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Cohen-Mansfiel|- |Considers inappropriate |No dates given |No details given |PsycLIT, MEDLINE, |83 |Pet therapy: 3 studies, all report |The volume of studies included in the |
|d 2001 | |behaviours in dementia; a | | |and a nursing | |improvements |overall review mean that some, but not |
| | |literature search on the | | |subset of MEDLINE | | |all of the studies are described, but |
| | |impact of | | | | | |all are given equal weight. |
| | |non-pharmacological | | | | | |Methodological issues are presented |
| | |interventions (to address | | | | | |within the discussion section, these |
| | |the issues of | | | | | |relate to diverse measurement methods, |
| | |understanding of the | | | | | |criteria for success, screening |
| | |interventions, their | | | | | |procedures, control procedures and |
| | |effects and their | | | | | |treatment of failures. Little or no |
| | |feasibility) | | | | | |account is taken of study design (RCT, |
| | | | | | | | |case study etc). |
Table 3a. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Thorgrimsen |++ |What is the evidence for |Search carried |Aroma*, complementary |Specialised Register contained |2 (all RCTs)|The additional analyses |Clear review with comprehensive |
|2003 / 2006 | |the efficacy of |out April 2006 |therap*, alternative |records from : CENTRAL, MEDLINE,| |(of only one RCT) |description of methodology, literature |
|(two papers | |aromatherapy as an | |therap*, essential oil*|EMBASE, PsycINFO, CINAHL, SIGLE,| |conducted revealed a |and findings. The conclusions are in |
|reporting the | |intervention for people | | |ISTP, INSIDE, Aslib Index to | |statistically significant |line with the findings. |
|same study) | |with dementia? | | |theses, Dissertation Abstract | |treatment effect in favour| |
| | | | | |(USA), | |of the aromatherapy | |
| | | | | | |intervention on measures | |
| | | | | |gov/, National Research | |of agitation and | |
| | | | | |Register, , | |neuropsychiatric symptoms,| |
| | | | | |LILACS, | |but there were several | |
| | | | | | |methodological | |
| | | | | |com, , | |difficulties with the | |
| | | | | | |study. | |
| | | | | |ml, ISRCTN Register, IPFMA | | | |
| | | | | |Clinical Trials Register, | | | |
| | | | | |Lundbeck Trial Registry; | | | |
| | | | | |journals: Complementary | | | |
| | | | | |Therapies in Medicine, | | | |
| | | | | |Complementary Therapies in | | | |
| | | | | |Nursing and Midwifery | | | |
Table 3b. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Aromatherapy
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |aromatherapy| | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Robinson 2006 |++ |To determine the clinical |Search carried |Full details of search |Included Cochrane Library, |2 |Overall no robust evidence|Clear review with comprehensive |
|/ 2007 (two | |and cost effectiveness and|out up to and |terms contained in |MEDLINE, EMBASE, Central CINAHL,| |of the efficacy the |description of methodology, literature |
|papers | |acceptability of |including 31 |appendix |Social Science Citation Index, | |evidence deemed to be of |and findings. The conclusions are in |
|reporting same| |non-pharmacological |March 2005 | |Science Citation Index, | |low quality. Two RCTs; one|line with the findings. |
|study) | |interventions to reduce | | |PsycINFO, ADEAR, National | |showed participants | |
| | |wandering dementia | | |Research Register, ETHX | |receiving essential oils | |
| | | | | |database, Bioethicsweb, ISTP, | |showed less wandering | |
| | | | | |ZETOC,, Journal of Dementia Care| |behaviour (marginal | |
| | | | | |(1999-2004), Dementia (2002-4), | |statistical significance);| |
| | | | | |personal contact with | |the other found no | |
| | | | | |specialists in the field | |difference. | |
|Diamond 2003 |- |To review use of |1982-2002 |Numerous terms listed |Medline, Research Council for |7 |The studies among persons |Likely to overestimate results as study |
| | |alternative substances to | |in paper – but no |Complementary Medicine, | |with dementia indicate |quality is not assessed – all appear to |
| | |ameliorate the cognitive, | |dementia terms |PsycINFO, Ingenta plc, Cochrane | |that aromatherapy may have|have been given equal weight |
| | |psychiatric and | |mentioned |Database of Systematic Reviews | |moderately beneficial | |
| | |behavioural symptoms of | | | | |effects. Better controlled| |
| | |dementia | | | | |studies with larger sample| |
| | | | | | | |sizes are needed to | |
| | | | | | | |evaluate the effect of | |
| | | | | | | |aromatherapy on the affect| |
| | | | | | | |and behaviour of persons | |
| | | | | | | |with dementia | |
Table 4. Behaviour Management: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Individualised Behaviour Management
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Robinson 2006 |++ |To determine the clinical |Search carried |Full details of search |Included Cochrane Library, |1 |This study did not provide|Clear review with comprehensive |
|/ 2007 (two | |and cost effectiveness and|out up to and |terms contained in |MEDLINE, EMBASE, Central CINAHL,| |evidence that the |description of methodology, literature |
|papers on same| |acceptability of |including 31 |appendix |Social Science Citation Index, | |intervention was effective|and findings. The conclusions are in |
|study) | |non-pharmacological |March 2005 | |Science Citation Index, | |in preventing/reducing |line with the findings. |
| | |interventions to reduce | | |PsycINFO, ADEAR, National | |wandering | |
| | |wandering dementia | | |Research Register, ETHX atabase,| | | |
| | | | | |Bioethicsweb, ISTP, ZETOC,, | | | |
| | | | | |Journal of Dementia Care | | | |
| | | | | |(1999-2004), Dementia (2002-4), | | | |
| | | | | |personal contact with | | | |
| | | | | |specialists in the field | | | |
|Livingston |+ |A systematic review of |Electronic |terms encompassing |Electronic databases; reference |25 |25 papers report on |Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |individual dementias |lists from individual and review| |non-dementia specific |let down by lack of detail in the search|
| | |to the management of |July 2003, Hand |and interventions – no |articles, Cochrane Library plus | |psychological therapies |strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |further details given |hand searched three journals | |for patients with |replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10| |(titles not given) | |dementia, nearly all |large number of papers included in the |
| | |of making evidence based |year period up to| | | |examined behavioural |review (162), other than highlighting |
| | |recommendations about the |July 2003 | | | |management techniques. The|the RCTs it is difficult to determine |
| | |use of these interventions| | | | |studies were judged to be |study design or details such as sample |
| | | | | | | |relatively high quality. |characteristics or setting. |
| | | | | | | |The authors report that | |
| | | | | | | |the findings of the larger| |
| | | | | | | |RCT were consistent and | |
| | | | | | | |positive, and the effects | |
| | | | | | | |lasted for months | |
Table 4 (cont). Behaviour Management: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Individualised Behaviour Management
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Verkaik 2005 |+ |The effect of psychosocial|Search carried |Numerous terms included|Pubmed, Cochrane CENTRAL/CCTR, |1 |There is limited evidence |Overall a comprehensive review; however,|
| | |methods on depressed, |out from |and listed |Cochrane Database of Systematic | |(one high quality RCT) |there is no discussion of the strength |
| | |aggressive and apathetic |September 2002 to| |Reviews, PsychINFO, EMBASE, | |that people with probable |of evidence for no effect / negative |
| | |behaviours of people with |February 2003 | |CINAHL, INVERT, NIVEL, Cochrane | |Alzheimer’s disease living|effect - only positive effect |
| | |dementia | | |Specialized Register, CDCIG, | |at home with depression | |
| | | | | |SIGLE, DARE. | |are less depressed when | |
| | | | | | | |their caregivers are | |
| | | | | | | |trained in using Behaviour| |
| | | | | | | |therapy-pleasant events or| |
| | | | | | | |behaviour therapy-problem | |
| | | | | | | |solving rather than given | |
| | | | | | | |standard information from | |
| | | | | | | |a therapist or no | |
| | | | | | | |information/training. | |
| | | | | | | | | |
Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Clare 2007 |++ |To evaluate the |Search carried |Numerous, listed in |Specialised Register contained |9 (all RCTs)|The available evidence remains limited,|Comprehensive review with |
| | |effectiveness and impact |out April 2006 |paper |records from : CENTRAL, MEDLINE,| |but there is still no indication of any|clear search strategy, |
| | |of cognitive training and |and September | |EMBASE, PsycINFO, CINAHL, SIGLE,| |significant effects from cognitive |terms and criteria but as |
| | |cognitive rehabilitation |2006 | |ISTP, INSIDE plus Theses and | |training. |noted by the authors The|
| | |interventions aimed at | | |on-going trials | |The use of standardised |use of standardised |
| | |improving memory and other| | | | |neuropsychological measures may result |neuropsychological |
| | |aspects of cognitive | | | | |in positive effects on daily living |measures may result in |
| | |functioning for people in | | | | |capabilities going unrecognised. |positive effects on daily |
| | |the early stages of | | | | |It is not possible at to draw |living capabilities going |
| | |Alzheimer’s disease or | | | | |conclusions about the efficacy of |unrecognised. |
| | |vascular dementia | | | | |individualised cognitive rehabilitation| |
| | | | | | | |interventions for people with early | |
| | | | | | | |stage dementia due to lack of RCTs. | |
|Grandmaison |+ |To review the evidence on |As indicated by |Numerous search terms |Medline (1971), PsychINFO |17 |The results suggest that it is possible|Comprehensive review but |
|2003 | |the efficacy of |database |outlined in text |(1887-2001) | |to stimulate memory in AD. The |inclusion of only two |
| | |stimulation strategies or | |Clear | | |errorless learning, spaced retrieval, |databases for the search |
| | |programmes with the AD | |inclusion/exclusion | | |and vanishing clues techniques, |may have led to the |
| | |population | |criteria | | |together with the dyadic approach seem |exclusion of pertinent |
| | | | | | | |to present the best training methods |studies. |
| | | | | | | |for patients with AD. But there is a |As the authors suggest, |
| | | | | | | |need for more RCTs to validate this |whilst the evidence |
| | | | | | | |treatment approach. |suggests positive results |
| | | | | | | | |the majority of studies |
| | | | | | | | |contain small sample |
| | | | | | | | |numbers making |
| | | | | | | | |identification of |
| | | | | | | | |statistically significant |
| | | | | | | | |improvements difficult. |
Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Sitzer 2006 |++ |To systematically review |Up to 2004 as per|Cognitive |Medline (1953-2004) & PsychINFO |19 |Cognitive training evidenced promise in|Overall a well present and|
| | |the literature and |details of |rehabilitation, |(1840-2004) | |the treatment of AD, with primarily |clear review and analysis.|
| | |summarise the effect of |databases |cognitive training, | | |medium effect sizes for learning |However, it is interesting|
| | |cognitive training for | |cognitive remediation, | | |memory, executive functioning, ADL, |to note that studies |
| | |Alzheimer’s disease | |memory training, | | |general cognitive problems, depression,|identified as higher |
| | | | |attention training, | | |self-rated general functioning. |quality ‘painted a less |
| | | | |Alzheimer’s disease | | |Restorative strategies demonstrated the|optimistic picture of |
| | | | | | | |greatest effect on functioning. |efficacy’. The studies |
| | | | | | | |Limitations: small number of well |come under the cognitive |
| | | | | | | |controlled studies; small sample |training umbrella but |
| | | | | | | |numbers and difficulties associated |include a diverse range of|
| | | | | | | |with outcome measures. Evidence of |interventions (including |
| | | | | | | |maintenance of gains is based on only |reality orientation and |
| | | | | | | |six papers. |reminiscence therapy). |
Table 5b. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training
|Author, |Overall |Research Question |Years covered |Search terms |Databases searched |No of cognition studies |Author’s Conclusions |Comments |
|Year |assessment of| | |used | |reviewed | | |
| |the review | | | | | | | |
|Bates 2004 |+ |To investigate the |Search carried |Numerous |15 electronic databases, |1 |The study found no |Overall although most studies were |
| | |effectiveness of |out between April| |10 grey literature sources| |significant improvement in|excluded on grounds of quality, the four|
| | |psychological |and June 2002 | |– details contained in | |functional and cognitive |retained had low sample size and no |
| | |interventions for people | | |study appendix | |ability. Therefore the |power calculations which could overstate|
| | |with milder dementing | | | | |review did not find any |positive results |
| | |illness | | | | |evidence of the | |
| | | | | | | |effectiveness of | |
| | | | | | | |procedural memory | |
| | | | | | | |stimulation. | |
|Livingston |+ |A systematic review of |Electronic |terms |Electronic databases; |4 |Mostly consistent evidence|Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |encompassing |reference lists from | |that cognitive stimulation|let down by lack of detail in search |
| | |to the management of |July 2003, Hand |individual |individual and review | |therapy improves aspects |strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |dementias and |articles, Cochrane Library| |of neuropsychiatric |replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10|interventions –|plus hand searched three | |symptoms immediately and |large number of papers included in the |
| | |of making evidence based |year period up to|no further |journals (titles not | |for some months |review (162), other than highlighting |
| | |recommendations about the |July 2003 |details given |given) | |afterwards. |the RCTs it is difficult to determine |
| | |use of these interventions| | | | |Three of the four RCTs |study design or details such as sample |
| | | | | | | |showed positive |characteristics or setting. |
| | | | | | | |improvements | |
Table 6. Counselling: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Counselling
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions on |Comments |
|Year |assessment of | | | | |counselling |Counselling Study | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Bates 2004 |+ |To investigate the |Search carried |Numerous |15 electronic databases, 10 |1 |Effectiveness of the individual|Overall although most studies were |
| | |effectiveness of |out between | |grey literature sources – | |counselling sessions was not |excluded on grounds of quality, the |
| | |psychological |April and June | |details contained in study | |demonstrated on the outcome |four retained had low sample size and|
| | |interventions for |2002 | |appendix | |measures used. |no power calculations which could |
| | |people with milder | | | | | |overstate positive results |
| | |dementing illness | | | | | | |
Table 7. Environmental Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Environmental Interventions
|Author, |Overall |Research Question |Years |Search terms used |Databases searched|No of studies |Authors’ Conclusions |Comments |
|Year |assessment of| |covered | | |reviewed | | |
| |the review | | | | | | | |
|Livingston |+ |A systematic review of |Electronic|terms encompassing |Electronic |19 |8 studies investigated the effects of |Overall a comprehensive review that is |
|2005 | |psychological approaches |database |individual dementias|databases; | |changing the visual environment: consistent |let down by lack of detail in search |
| | |to the management of |up to July|and interventions – |reference lists | |evidence from lower grade studies for |strategy which means it is not |
| | |neuropsychiatric symptoms |2003, Hand|no further details |from individual | |changing the environment to obscure the exit.|replicable. In addition, due to the very|
| | |of dementia with the aim |searched |given |and review | |2 studies investigated use of mirrors: |large number of papers included in the |
| | |of making evidence based |three | |articles, Cochrane| |inconclusive/inconsistent evidence |review (162), other than highlighting |
| | |recommendations about the |journal | |Library plus hand | |3 studies investigated use of signposting: |the RCTs it is difficult to determine |
| | |use of these interventions|during 10 | |searched three | |inconclusive/inconsistent evidence |study design or details such as sample |
| | | |year | |journals (titles | |5 studies in group living: |characteristics or setting. |
| | | |period up | |not given) | |inconclusive/inconsistent evidence | |
| | | |to July | | | |I study unlocked doors: | |
| | | |2003 | | | |inconclusive/inconsistent evidence | |
|Cohen-Mansfiel|- |Considers inappropriate |No dates |No details given |PsycLIT, MEDLINE, |6 |2 studies showed free access to an outdoor |The volume of studies included in the |
|d 2001 | |behaviours in dementia; a |given | |and a nursing | |area,result in decreased agitation; 2 studies|overall review (n=83) mean that some, |
| | |literature search on the | | |subset of MEDLINE | |found a simulated natural environment |but not all of the studies are |
| | |impact of | | | | |decreased agitated behaviours; 2 studies |described, but all are given equal |
| | |non-pharmacological | | | | |report reduced agitation after initiation of|weight. Methodological issues are |
| | |interventions (to address | | | | |a reduced stimulation environment. |presented within the discussion section,|
| | |the issues of | | | | | |these relate to diverse measurement |
| | |understanding of the | | | | | |methods, criteria for success, screening|
| | |interventions, their | | | | | |procedures, control procedures and |
| | |effects and their | | | | | |treatment of failures. Little or no |
| | |feasibility) | | | | | |account is taken of study design (RCT, |
| | | | | | | | |case study etc). |
Table 7 (cont) . Environmental Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Environmental Interventions
|Author, |Overall |Research Question |Years |Search terms used |Databases searched|No of studies |Authors’ Conclusions |Comments |
|Year |assessment of| |covered | | |reviewed | | |
| |the review | | | | | | | |
|Spira 2006 |- |To critically review the |1970-2004 |No details given |PsycINFO |6 |Overall the 23 reviewed studies collectively |Only one database searched which is |
| | |empirical literature on | | | | |provide evidence that warrants optimism |likely to have limited papers |
| | |behavioural interventions | | | | |regarding the application of behavioural |identified. |
| | |to reduce agitation in | | | | |principles to the management of agitation |The conclusions drawn by the author |
| | |older adults with dementia| | | | |among older adults with dementia. Although |suggest the studies collectively provide|
| | | | | | | |some of the results of some of the studies |evidence. Unfortunately the prevalence |
| | | | | | | |are mixed and several studies revealed |of single subject and case study designs|
| | | | | | | |methodological shortcomings, many offered |together with the majority of studies |
| | | | | | | |innovations that can be used in future, more |measuring the occurrence of target |
| | | | | | | |rigorously designed, intervention studies. |behaviours by direct observation means |
| | | | | | | | |this evidence is, at best weak and |
| | | | | | | |Wandering and hazardous behaviour: taken |likely to over estimate the results. |
| | | | | | | |together the 6 studies can have clinically | |
| | | | | | | |meaningful effects on wandering in older | |
| | | | | | | |adults with dementia; but contradictory | |
| | | | | | | |results were obtained concerning the utility | |
| | | | | | | |of particular stimuli. | |
| | | | | | | | | |
| | | | | | | |Disruptive vocalization: only one single | |
| | | | | | | |subject case study. | |
| | | | | | | | | |
| | | | | | | | | |
Table 8a. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of | | | | |studies | | |
| |the review | | | | |reviewed | | |
|Forbes 2007 |++ |What |Search carried out|Bright light*, light|Specialised Register contained |5 (all RCTs)|There is insufficient evidence to |A comprehensive review containing |
| | |recommendations |December 2005 |box*, light visor*, |records from : CENTRAL, | |assess the value of bright light |RCTs only. |
| | |can be made | |dawn-dusk*, |MEDLINE, EMBASE, PsycINFO, | |therapy (BLT) for people with | |
| | |regarding the | |phototherapy (MESH),|CINAHL, SIGLE, ISTP, INSIDE, | |dementia. The available studies are | |
| | |efficacy of light | |phototherapy, |Aslib Index to theses, | |of poor quality and further research | |
| | |therapy in | |“phototherapy”, |Dissertation Abstract (USA), | |is required | |
| | |managing | |“light therapy”, | | | |
| | |disturbances of | |“light treatment”, |.gov/, National Research | | | |
| | |sleep, behaviour, | |light* |Register, , | | | |
| | |mood and/or | | |LILACS, | | | |
| | |cognition | | | | | |
| | |associated with | | |.com, ,| | | |
| | |dementia? | | | | | |
| | | | | |tml, ISRCTN Register, IPFMA | | | |
| | | | | |Clinical Trials Register | | | |
|Skjerve 2004 |+ |What does the |1980 – September |Light, therapy, |MEDLINE, PsycINFO, Cochrane |21 |Despite 6 RCTs (one with good power) |Although some methods are provided |
| | |literature say |2003 |treatment, | | |showing positive results for some |regarding the literature search the |
| | |about the | |phototherapy, | | |aspects the authors do not draw any |process of selection, extraction and |
| | |efficacy, clinical| |dementia | | |conclusions on efficacy. The authors |synthesis are not presented. |
| | |practicability and| | | | |recommend study into the effects on |There is no report of the initial |
| | |safety of light | | | | |people with mild dementia suggesting |number of hits. Inclusion criteria |
| | |treatment for | | | | |successful treatment may be more |are given but not the process for |
| | |behavioural and | | | | |likely and may reduce the need for |identifying the 21 included studies. |
| | |psychological | | | | |institutionalisation. Different |Despite several RCTs (one with good |
| | |symptoms of | | | | |effects may be due to differences in |power) showing positive results for |
| | |dementia? | | | | |treatment (brightness, duration, |some aspects the authors do not draw |
| | | | | | | |timing) or condition (e.g. vascular |any conclusions on efficacy. |
| | | | | | | |dementia) which have been | |
| | | | | | | |insufficiently tested. | |
Table 8a (cont). Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of | | | | |studies | | |
| |the review | | | | |reviewed | | |
|Kim 2003 |- |To evaluate the effects|No clear |Not reported |Not reported |14 |A need clearly exists for |Limited search methodology is reported |
| | |of bright light therapy| | | | |well-designed controlled |and no methodology for data extraction /|
| | |on the sleep and | | | | |studies to look at the |selection / synthesis. |
| | |behaviour of dementia | | | | |relationship among |Database(s) not reported, nor search |
| | |patients | | | | |dementia, agitation, |terms, number of initial hits or process|
| | | | | | | |sleep-wakefulness and |for selection. Inclusion/exclusion |
| | | | | | | |bright light in community |criteria are reported. |
| | | | | | | |or nursing home |Adequate discussion of methodological |
| | | | | | | |populations. |problems but divorced from the selection|
| | | | | | | | |of studies and results. |
| | | | | | | | |The lack of reporting of the literature |
| | | | | | | | |search and wide inclusion criteria could|
| | | | | | | | |overestimate effects, however the |
| | | | | | | | |authors do not draw any conclusions |
| | | | | | | | |regarding effects. |
Table 8b. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Light Therapy
|Author, |Overall assessment|Research Question |Years covered |Search terms used |Databases searched |No of light|Author’s Conclusions |Comments |
|Year |of the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Cohen-Mansfiel|- |Considers |No dates given |No details given |PsycLIT, MEDLINE, and a nursing |7 |The results of the 7 |The volume of studies included in the |
|d 2001 | |inappropriate | | |subset of MEDLINE | |studies are inconclusive, |overall review mean that some, but not |
| | |behaviours in | | | | |some report a significant |all of the studies are described, but |
| | |dementia; a | | | | |decrease and some report a|all are given equal weight. |
| | |literature search on| | | | |trend. These differences |Methodological issues are presented |
| | |the impact of | | | | |may stem from differences |within the discussion section, these |
| | |non-pharmacological | | | | |in design and measurement |relate to diverse measurement methods, |
| | |interventions (to | | | | |or from differences in |criteria for success, screening |
| | |address the issues | | | | |population. |procedures, control procedures and |
| | |of understanding of | | | | | |treatment of failures. Little or no |
| | |the interventions, | | | | | |account is taken of study design (RCT, |
| | |their effects and | | | | | |case study etc). |
| | |their feasibility) | | | | | | |
Table 9a. Massage and Touch: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Viggo Hansen |++ |To assess the |Search carried |Trials identified from |Specialised Register contained |2 (both |Some evidence is available|Clear review with comprehensive |
|2006 | |effectiveness of a range |out July 2005. No|the Specialised |records from : CENTRAL, MEDLINE,|RCTs) |to support the efficacy of|description of methodology, literature |
| | |of massage and touch |date exclusion |Register of the |EMBASE, PsycINFO, CINAHL, SIGLE,| |two specific applications:|and findings. However, the authors may |
| | |therapies offered to | |Cochrane Dementia and |ISTP, INSIDE, Aslib Index to | |the use of hand massage |overstate the strength of evidence on |
| | |patients with dementia | |Cognitive Improvement |theses, Dissertation Abstract | |for an immediate and short|the basis of two small and separate |
| | | | |Group using the terms |(USA), | |term reduction in agitated|studies. |
| | | | |massage, reflexology, | |behaviour, and the | |
| | | | |touch, shiatsu |gov/, National Research | |addition of touch to | |
| | | | | |Register, , | |verbal encouragement to | |
| | | | | |LILACS, | |eat for the normalization | |
| | | | | | |of nutritional intake. | |
| | | | | |com, , | | | |
| | | | | | | | |
| | | | | |ml, ISRCTN Register, IPFMA | | | |
| | | | | |Clinical Trials Register, | | | |
Table 9b. Massage and Touch: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Massage and Touch
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Livingston |+ |A systematic review of |Electronic |terms encompassing |Electronic databases; reference |3 |The authors identify 3 |Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |individual dementias |lists from individual and review| |studies in this area only |let down by lack of detail in search |
| | |to the management of |July 2003, Hand |and interventions – no |articles, Cochrane Library plus | |one of which is a RCT. The|strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |further details given |hand searched three journals | |authors report no evidence|replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10| |(titles not given) | |for sustained usefulness. |large number of papers included in the |
| | |of making evidence based |year period up to| | | |However, the RCT, |review (162), other than highlighting |
| | |recommendations about the |July 2003 | | | |comparing calming music, |the RCTs it is difficult to determine |
| | |use of these interventions| | | | |hand massage, music |study design or details such as sample |
| | | | | | | |followed by massage or |characteristics or setting. |
| | | | | | | |music and massage | |
| | | | | | | |simultaneously for 10 | |
| | | | | | | |minutes each, finds all | |
| | | | | | | |groups had reduced | |
| | | | | | | |agitation relative to | |
| | | | | | | |comparison group. Effect | |
| | | | | | | |lasted for 1 hour. | |
|Cohen-Mansfiel|- |Considers inappropriate |No dates given |No details given |PsycLIT, MEDLINE, and a nursing |83 |Massage touch: 6 studies, |The volume of studies included in the |
|d 2001 | |behaviours in dementia; a | | |subset of MEDLINE | |one reported unequivocal |overall review) mean that some, but not |
| | |literature search on the | | | | |success, the others either|all of the studies are described, but |
| | |impact of | | | | |a positive trend, partial |all are given equal weight. |
| | |non-pharmacological | | | | |effects (physical and |Methodological issues are presented |
| | |interventions (to address | | | | |verbal behaviours) or no |within the discussion section, these |
| | |the issues of | | | | |effect (aggression) |relate to diverse measurement methods, |
| | |understanding of the | | | | | |criteria for success, screening |
| | |interventions, their | | | | | |procedures, control procedures and |
| | |effects and their | | | | | |treatment of failures. Little or no |
| | |feasibility) | | | | | |account is taken of study design (RCT, |
| | | | | | | | |case study etc). |
Table10a. Music Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of studies |Author’s Conclusions |Comments |
|Year |assessment of| | | | |reviewed | | |
| |the review | | | | | | | |
|Sung 2005 |++ |To provide a summary of |1993 - 2005 |‘included’ preferred |MEDLINE, CINAHL, PsychINFO, PsycARTICLES, |8 |Music listening |Clear review with |
| | |the current state of | |music, individualized |Cochrane Database of Systematic Reviews, | |intervention matched with |comprehensive description|
| | |knowledge about the | |music, music, agitated | | |personal preferences has |of methodology, |
| | |effects of preferred music| |behaviours, dementia, | | |positive effects in |literature and findings. |
| | |on agitated behaviours for| |Alzheimer’s disease, | | |reducing occurrence of |The conclusions are in |
| | |older people with dementia| |music and dementia, | | |some forms of agitated |line with the findings. |
| | |and to discuss the | |music and Alzheimer’s | | |behaviours in older people| |
| | |implications for future | |disease | | |with dementia; but a |Of particular strength is|
| | |research and practice | | | | |number of methodological |the concentration on the |
| | | | | | | |limitations were apparent |use of preferred music |
| | | | | | | |in the studies reviewed |only |
|Vink 2003 |+ + |To assess the efficacy of |Search conducted |Trials identified from |Specialised Register contained records from :|5 (all RCTs) |Despite the five studies |Clear review with |
| | |music therapy in the |December 2005, |the Specialised |CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, | |claiming a favourable |comprehensive description|
| | |treatment of behavioural, |updated January |Register of the |SIGLE, ISTP, INSIDE, Aslib Index to theses, | |effect of music therapy in|of methodology, |
| | |social, cognitive and |2006. No explicit|Cochrane Dementia and |Dissertation Abstract (USA), | |reducing problems in the |literature and findings. |
| | |emotional problems of |date exclusion |Cognitive Improvement |, | |behavioural, social, |The conclusions are in |
| | |older people with dementia| |Group using the term |National Research Register, | |emotional and cognitive |line with the findings. |
| | | | |music |, LILACS, | |domains the review does | |
| | | | | |, | |not endorse those claims |Of particular strength is|
| | | | | |, | |owing to the poor quality |the inclusion of only |
| | | | | |, ISRCTN | |of the studies. |RCTs |
| | | | | |Register, IPFMA Clinical Trials Register, | | | |
| | | | | |Geronlit, Research Index, Carl Uncover, | | | |
| | | | | |Muscia, Omni | | | |
Table 10a (cont). Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of studies |Author’s Conclusions |Comments |
|Year |assessment of | | | | |reviewed | | |
| |the review | | | | | | | |
|Sherratt 2004 |+ |To review clinical |Assume search |Music, music therapy, |CINAHL, MEDLINE, EMBASE, |21 |Most studies reported the |A comprehensive review that whilst |
| | |empirical studies |conducted 2003. |dementia, review |PsychINFO, ClinPSYCH | |effects of music to be |discussing a number of methodological|
| | |looking at the effects|No explicit date | | | |effective in decreasing a range|issues (including, for example, |
| | |of a variety of music |exclusion | | | |of challenging behaviours |observational data collection |
| | |on the emotional and | | | | |including aggression, |methods) does not address study |
| | |behavioural responses | | | | |agitation, wandering, |design in relation to assessment of |
| | |in people with | | | | |repetitive vocalizations and |quality |
| | |dementia | | | | |irritability. Music was also | |
| | | | | | | |found to increase reality | |
| | | | | | | |orientation scores, time spent | |
| | | | | | | |with one’s meal and social | |
| | | | | | | |behaviour. | |
| | | | | | | | | |
| | | | | | | |Not clear from table or text | |
| | | | | | | |of the number of RCTs | |
|Lou 2001 |- |To review |1990- to present |Music therapy, |MEDLINE, CINAHL |7 |Music can be useful as an |The review question focus is |
| | |interventions using |(assume 2001) |agitated behaviour, | | |intervention to help patients |specifically concerned with reduction|
| | |music to decrease | |demented elderly | | |deal with agitated behaviour |of agitated behaviour. The search |
| | |agitated behaviour of | | | | |problems and can increase |strategy is not clear in as much as |
| | |the demented elderly | | | | |patients’ quality of life but |inclusion criteria is preferably with|
| | |person | | | | |the overall weakness and |demented elderly and no details are |
| | | | | | | |limitations in study design are|given of the numbers of papers |
| | | | | | | |considerable. |identified in initial screening. |
| | | | | | | | |Limiting the search to two databases |
| | | | | | | |Not clear from table or text |may have reduced the papers |
| | | | | | | |of the number of RCTs |identified |
Table 10a (cont). Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of music |Author’s Conclusions on Music |Comments |
|Year |assessment of | | | | |therapy studies|Therapy Study | |
| |the review | | | | |reviewed | | |
|Nugent 2002 |- |Examine the use of |1980 – present |No details given |Psychlit, CAIRSS, CINAHL, |19 |The review supported the |The author’s conclusions are likely |
| | |music and music therapy|(assume 2002) | |Dissertation Abstracts | |premise that music and music |to overstate the effectiveness of the|
| | |used for people who | | |International plus reviewed | |therapy interventions reduce |interventions as all studies given |
| | |have ADRDs (Alzheimers | | |articles in: Journal of Music| |the occurrence and frequency of|equal weight irrespective of study |
| | |disease and related | | |Therapy, Music Therapy | |agitated behaviours for those |quality. There is insufficient detail|
| | |disorders) and display | | |Perspectives, The Australian | |with Alzheimer’s disease and |or assessment of the quality of the |
| | |agitated behaviours | | |Journal of Music Therapy, The| |related disorders. Music |papers |
| | | | | |British Journal of Music | |therapy may prevent extreme | |
| | | | | |Therapy | |forms of agitation. Wandering | |
| | | | | | | |and general restlessness | |
| | | | | | | |reduced significantly. However,| |
| | | | | | | |more rigorous designs that | |
| | | | | | | |include refined measuring tools| |
| | | | | | | |and studies that have larger | |
| | | | | | | |sample sizes are required to | |
| | | | | | | |gather more data. | |
Table 10b. Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of music |Author’s Conclusions on Music |Comments |
|Year |assessment of | | | | |therapy studies|Therapy Study | |
| |the review | | | | |reviewed | | |
|Robinson 2006, |++ |To determine the |Search carried |Full details of |Included Cochrane Library, |1 |Review found no evidence for |Clear review with comprehensive |
|2007 (two | |clinical and cost |out up to and |search terms |MEDLINE, EMBASE, Central | |the effectiveness of music |description of methodology, |
|papers report | |effectiveness and |including 31 |contained in |CINAHL, Social Science | |therapy; the identified |literature and findings. The |
|same study) | |acceptability of |March 2005 |appendix |Citation Index, Science | |evidence was assessed to be of |conclusions are in line with the |
| | |non-pharmacological | | |Citation Index, PsycINFO, | |low quality. One RCT that |findings. |
| | |interventions to reduce| | |ADEAR, National Research | |showed conflicting evidence | |
| | |wandering dementia | | |Register, ETHX atabase, | |based on different measures | |
| | | | | |Bioethicsweb, ISTP, ZETOC,, | | | |
| | | | | |Journal of Dementia Care | | | |
| | | | | |(1999-2004), Dementia | | | |
| | | | | |(2002-4), personal contact | | | |
| | | | | |with specialists in the field| | | |
|Warner 2006 |++ |What are the effects of|Assume up to |Full details of |Cochrane Database of |3 |Music therapy has unknown |Clear review with comprehensive |
| | |treatment on cognitive |and including |search strategy |Systematic Reviews (on | |effectiveness. |description of methodology. Only |
| | |symptoms of dementia? |February 2006 |contained on BMJ |CD-ROM) | |One RCT found that music based |includes systematic reviews and RCTs.|
| | |What are the effects of| |Clinical Evidence |Medline [see search strategy]| |exercise improved cognition |However, search terms are unclear. |
| | |treatments on | |website |Embase [see search strategy] | |after 3 months compared with |Quality assessment appears to have |
| | |behavioural and | | |Other databases (e.g. | |one to one conversation with a |been undertaken within the inclusion |
| | |psychological symptoms | | |PsycInfo) as appropriate | |therapist. Poor studies |criteria |
| | |of dementia? | | |Centre for Reviews and | |identified by two systematic | |
| | | | | |Dissemination (CRD) website | |reviews provided insufficient | |
| | | | | |Database of Abstracts of | |evidence to assess the effects | |
| | | | | |Reviews of Effects (DARE) | |of music therapy in people with| |
| | | | | |online database | |dementia | |
| | | | | |Health Technology Assessment | | | |
| | | | | |(HTA) online database | | | |
| | | | | |National Institute for Health| | | |
| | | | | |and Clinical Excellence | | | |
| | | | | |(NICE) website | | | |
| | | | | |TRIP online database | | | |
Table 10b (cont) Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of music |Author’s Conclusions on Music |Comments |
|Year |assessment of | | | | |therapy studies|Therapy Study | |
| |the review | | | | |reviewed | | |
|Livingston |+ |A systematic review of |Electronic |terms encompassing |Electronic databases; |24 |Consistent evidence suggests |Overall a comprehensive review that |
|2005 | |psychological |database up to |individual dementias|reference lists from | |music therapy decreases |is let down by lack of detail in |
| | |approaches to the |July 2003, Hand|and interventions – |individual and review | |agitation during sessions and |search strategy which means it is not|
| | |management of |searched three |no further details |articles, Cochrane Library | |immediately after. There is |replicable. In addition, due to the |
| | |neuropsychiatric |journal during |given |plus hand searched three | |however no evidence that music |very large number of papers included |
| | |symptoms of dementia |10 year period | |journals (titles not given) | |therapy is useful for treatment|in the review (162), other than |
| | |with the aim of making |up to July 2003| | | |of neuropsychiatric symptoms in|highlighting the RCTs it is difficult|
| | |evidence based | | | | |the longer term. |to determine study design or details |
| | |recommendations about | | | | |Six RCTs ; all showed |such as sample characteristics or |
| | |the use of these | | | | |improvements in disruptive |setting. |
| | |interventions | | | | |behaviour | |
|Watson 2006 |+ |Is there evidence for |Up to December |feeding, eating, |CINAHL, Medline, EMBASE and |13 |The studies are characterised |The quality assessment criteria is |
| | |any effective |2003 |dementia, mealtimes |Cochrane | |by small sample sizes, there is|not clear. The results section |
| | |interventions to assist| | | | |a lack of RCTs and this type of|provides a description of the studies|
| | |older people with | | | | |intervention is fraught with |but, more critical assessment is |
| | |dementia to feed? | | | | |the problem of confounding |provided in the discussion section |
| | | | | | | |variables. |specifically related to music therapy|
| | | | | | | | |and assessment of feeding difficulty.|
| | | | | | | | |The search terms are likely to have |
| | | | | | | | |limited identification of relevant |
| | | | | | | | |studies. |
Table 10b (cont) Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of music |Author’s Conclusions on Music |Comments |
|Year |assessment of | | | | |therapy studies|Therapy Study | |
| |the review | | | | |reviewed | | |
|Cohen-Mansfield|- |Considers inappropriate|No dates given |No details given |PsycLIT, MEDLINE, and a |11 |11 studies were identified, all|The volume of studies included in the|
|2001 | |behaviours in dementia;| | |nursing subset of MEDLINE | |but one reported either |overall review (n=83) mean that some,|
| | |a literature search on | | | | |significant reduction or |but not all of the studies are |
| | |the impact of | | | | |positive trend in some |described, but all are given equal |
| | |non-pharmacological | | | | |inappropriate behaviours. One |weight. Methodological issues are |
| | |interventions (to | | | | |reported no effect |presented within the discussion |
| | |address the issues of | | | | | |section, these relate to diverse |
| | |understanding of the | | | | | |measurement methods, criteria for |
| | |interventions, their | | | | | |success, screening procedures, |
| | |effects and their | | | | | |control procedures and treatment of |
| | |feasibility) | | | | | |failures. Little or no account is |
| | | | | | | | |taken of study design (RCT, case |
| | | | | | | | |study etc). |
Table 11a. Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall assessment|Research |Years |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |of the review |Question |covered | | |studies | | |
| | | | | | |reviewed | | |
|Eggermont 2006|++ |To evaluate the|1974 -2005 |Physical activity, exercise, |Pubmed, Web of |27 |Taking the methodological quality of the |A comprehensive review with well |
| | |effect of | |physical therapy, fitness |Science, PsycINFO, | |studies and differences between interventions|described methodology using |
| | |planned | |training, behavioural problems, |Biomed Central | |into consideration, we conclude that |established criteria to assess |
| | |physical | |disruptive behaviour, mood, | | |sustained walking in particular may benefit |quality. The conclusions appear |
| | |activity | |depression, anxiety, aggression, | | |affective behaviour (mood). |consistent with the findings based|
| | |programmes on | |agitation, grief, happiness, | | |Taken together (the studies) physical |primarily on evidence from RCTs. |
| | |mood sleep and | |apathy, emotional problems, | | |activity appears to have a beneficial impact | |
| | |functional | |personality, quality of life, | | |on the quality of sleep. |. |
| | |activity in | |sleep, restlessness, wandering, | | |Taken together (the studies) physical | |
| | |people with | |general health, functional | | |activity may have positive effects on | |
| | |dementia | |ability, ADL, dementia, demented, | | |functional ability in care home residents but| |
| | | | |Alzheimer’s disease, nursing home | | |only when a long lasting exercise programme | |
| | | | |residents, cognitive impairment, | | |is applied. | |
| | | | |cognitively impaired, mild | | |Affective behaviour (mood) – 5 RCTs showed | |
| | | | |cognitive impairment | | |inconsistent findings. Two showed positive | |
| | | | | | | |effects. Of those negative findings one study| |
| | | | | | | |had a short intervention period (5 days); the| |
| | | | | | | |others two did not involve walking; hence | |
| | | | | | | |suggestion that walking may be key. | |
| | | | | | | | | |
| | | | | | | |Sleep - 3 RCTs showed beneficial effect – | |
| | | | | | | |conclude effective for sleep | |
| | | | | | | | | |
| | | | | | | |Functional ability: 1 RCT, this showed a | |
| | | | | | | |positive effect | |
Table 11a (cont) . Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall assessment|Research |Years |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |of the review |Question |covered | | |studies | | |
| | | | | | |reviewed | | |
|Penrose 2005 |- |To appraise |Up to |Aged, aging, older adults, |MEDLINE, PREMEDLINE,|Unclear |Lack of strong evidence of statistical |A weak systematic review. Many of |
| | |published |December |elderly, geriatric, Alzheimer’s |PsycINFO, ISI Web of| |significance to prescribe exercise/physical |the studies reported do not |
| | |literature on |2004 |disease, dementia, demented, |Science, CINAHL, | |activity to maintain cognitive function or |reflect the review question (and |
| | |the role of | |exercise, physical activity, |AMED, ALL EMB | |prevent cognitive decline in persons with AD.|do not include participants with |
| | |exercise, | |resistance training, endurance |Reviews (Cochrane | | |AD). It would appear that the |
| | |including | |training, aerobic exercise, |DSR, ACP Journal | | |inclusion/exclusion criterion |
| | |aerobic and | |mental, cognitive impairment, |Club, DARE, CCTR, | | |were not sufficiently focussed. |
| | |resistance | |congnition, cognitive function |SPORTDiscus, | | | |
| | |training , in | | |OTseeker, PEDro | | |It is unclear how many studies are|
| | |maintaining or | | | | | |included or whether primarily |
| | |improving the | | | | | |those with positive results were |
| | |cognitive | | | | | |reported; if this latter point is |
| | |function of | | | | | |true then this may bias the review|
| | |persons with | | | | | |in favour of intervention. |
| | |Alzheimer’s | | | | | | |
| | |disease | | | | | |The two RCTs reported both have |
| | | | | | | | |small sample numbers. It is not |
| | | | | | | | |clear whether more RCTs were |
| | | | | | | | |identified. |
Table 11b. Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Exercise/Physical Activity
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of | | | | |exercise | | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Robinson 2006 / |++ |To determine the |Search carried |Full details of search |Included Cochrane Library, |1 |The study produced some |Clear review with comprehensive |
|2007 (two papers | |clinical and cost |out up to and |terms contained in |MEDLINE, EMBASE, Central CINAHL,| |evidence that moderate |description of methodology, |
|on same study) | |effectiveness and |including 31 |appendix |Social Science Citation Index, | |intensity exercise may reduce |literature and findings. The |
| | |acceptability of |March 2005 | |Science Citation Index, | |wandering. One RCT that showed |conclusions are in line with the |
| | |non-pharmacological | | |PsycINFO, ADEAR, National | |significant reduction in |findings. |
| | |interventions to | | |Research Register, ETHX atabase,| |wandering | |
| | |reduce wandering | | |Bioethicsweb, ISTP, ZETOC,, | | | |
| | |dementia | | |Journal of Dementia Care | | | |
| | | | | |(1999-2004), Dementia (2002-4), | | | |
| | | | | |personal contact with | | | |
| | | | | |specialists in the field | | | |
|Livingston |+ |A systematic review |Electronic |Terms encompassing |Electronic databases; reference |4 |Graded the level of evidence as|Overall a comprehensive review |
|2005 | |of psychological |database up to |individual dementias |lists from individual and review| |troublingly inconsistent or |that is let down by lack of detail|
| | |approaches to the |July 2003, Hand |and interventions – no |articles, Cochrane Library plus | |inconclusive. Two RCTs (a |in search strategy which means it |
| | |management of |searched three |further details given |hand searched three journals | |walk-talk programme and a |is not replicable. In addition, |
| | |neuropsychiatric |journal during 10| |(titles not given) | |psychomotor activation |due to the very large number of |
| | |symptoms of dementia|year period up to| | | |programme) found no behavioural|papers included in the review |
| | |with the aim of |July 2003 | | | |effects |(162), other than highlighting the|
| | |making evidence | | | | | |RCTs it is difficult to determine |
| | |based | | | | | |study design or details such as |
| | |recommendations | | | | | |sample characteristics or setting.|
| | |about the use of | | | | | | |
| | |these interventions | | | | | | |
Table 11b (cont). Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Exercise/Physical Activity
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of | | | | |exercise | | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Cohen-Mansfield |- |Considers |No dates given |No details given |PsycLIT, MEDLINE, and a nursing |4 |Outdoor walks (2 studies) ; |The volume of studies included in |
|2001 | |inappropriate | | |subset of MEDLINE | |both found this intervention |the overall review) mean that |
| | |behaviours in | | | | |led to decreases in |some, but not all of the studies |
| | |dementia; a | | | | |inappropriate behaviour |are described, but all are given |
| | |literature search on| | | | | |equal weight. Methodological |
| | |the impact of | | | | |Physical activities (2 |issues are presented within the |
| | |non-pharmacological | | | | |studies); author makes no |discussion section, these relate |
| | |interventions (to | | | | |comment in these studies but |to diverse measurement methods, |
| | |address the issues | | | | |the table shows one study |criteria for success, screening |
| | |of understanding of | | | | |reported decreased agitation |procedures, control procedures and|
| | |the interventions, | | | | |during sensorimotor vs. the |treatment of failures. Little or |
| | |their effects and | | | | |traditional programme, the |no account is taken of study |
| | |their feasibility) | | | | |other reported non significant |design (RCT, case study etc). |
| | | | | | | |trend of decrease in agitation | |
| | | | | | | | | |
Table 12. Reality Orientation Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reality Orientation
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of studies |Author’s Conclusions |Comments |
|Year |assessment of| | | | |reviewed | | |
| |the review | | | | | | | |
|Livingston|+ |A systematic review of |Electronic |terms encompassing |Electronic databases; |11 |Inconclusive evidence. 2 RCTs, one |Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |individual |reference lists from | |showed no immediate benefit compared|let down by lack of detail in search |
| | |to the management of |July 2003, Hand |dementias and |individual and review | |with active ward orientation; the |strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |interventions – no |articles, Cochrane | |other showed a non-significant |replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10|further details |Library plus hand | |improvement when reminiscence |large number of papers included in the |
| | |of making evidence based |year period up to|given |searched three journals| |therapy was preceded by reality |review (162), other than highlighting |
| | |recommendations about the |July 2003 | |(titles not given) | |orientation but not vice versa |the RCTs it is difficult to determine |
| | |use of these interventions| | | | | |study design or details such as sample |
| | | | | | | | |characteristics or setting. |
|Bates 2004|+ |To investigate the |Search carried |Numerous |15 electronic |2 |Taking the two studies together |Overall although most studies were |
| | |effectiveness of |out between April| |databases, 10 grey | |there is evidence that reality |excluded on grounds of quality, the four|
| | |psychological |and June 2002 | |literature sources – | |orientation is an effective |retained had low sample size and no |
| | |interventions for people | | |details contained in | |intervention in improving cognitive |power calculations which could overstate|
| | |with milder dementing | | |study appendix | |ability. Neither study demonstrated |positive results |
| | |illness | | | | |that reality orientation is | |
| | | | | | | |effective in improving well-being or| |
| | | | | | | |improving communication, functional | |
| | | | | | | |performance and cognitive ability. | |
|Verkaik |+ |The effect of psychosocial|Search carried |Numerous terms |Pubmed, Cochrane |5 |The quality of the five studies was |Overall a comprehensive review; however,|
|2005 | |methods on depressed, |out from |included and listed|CENTRAL/CCTR, Cochrane | |assessed to be low. Only one study |there is no discussion of the strength |
| | |aggressive and apathetic |September 2002 to| |Database of Systematic | |found significant improvement in |of evidence for no effect / negative |
| | |behaviours of people with |February 2003 | |Reviews, PsychINFO, | |depression; a further study reported|effect - only positive effect |
| | |dementia | | |EMBASE, CINAHL, INVERT,| |improvement in apathy. There are no | |
| | | | | |NIVEL, Cochrane | |or insufficient indications that the| |
| | | | | |Specialized Register, | |intervention reduces depressive, | |
| | | | | |CDCIG, SIGLE, DARE. | |aggressive or apathetic behaviours | |
| | | | | | | |in people with dementia. | |
Table 13a. Reminiscence Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reminiscence Therapy
|Author, |Overall |Research Question |Years covered |Search terms |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | |used | |studies | | |
| |the review | | | | |reviewed | | |
|Warner 2006 |++ |What are the effects on |Up to and |Full details of|Cochrane Database of Systematic Reviews|1 |One systematic review (containing 4 |Clear review with |
| | |cognitive symptoms of |including |search strategy|(on CD-ROM) | |RCTs) found that reminiscence therapy |comprehensive description |
| | |dementia? |February 2006 |contained on |Medline [see search strategy] | |improved cognition but had no effect on|of methodology. Only |
| | |What are the effects of | |BMJ Clinical |Embase [see search strategy] | |behavioural measures. The included |includes systematic |
| | |treatments on behavioural | |Evidence |Other databases (e.g. PsycInfo) as | |studies used diverse measures and were |reviews and RCTs. However,|
| | |and psychological symptoms| |website |appropriate | |often small. Larger and better studies |search terms are unclear. |
| | |of dementia? | | |Centre for Reviews and Dissemination | |on reminiscence therapy are needed |Quality assessment |
| | | | | |(CRD) website | | |appears to have been |
| | | | | |Database of Abstracts of Reviews of | | |undertaken within the |
| | | | | |Effects (DARE) online database | | |inclusion criteria |
| | | | | |Health Technology Assessment (HTA) | | | |
| | | | | |online database | | | |
| | | | | |National Institute for Health and | | | |
| | | | | |Clinical Excellence (NICE) website | | | |
| | | | | |TRIP online database | | | |
|Woods 2005 |++ |Assess the effects of |Up to and |reminiscence |Specialised Register contained records |5 (data |The meta-analysis results were |A clear and concise |
| | |reminiscence therapy for |including May | |from : CENTRAL, MEDLINE, EMBASE, |extracted |statistically significant for |review. The conclusions |
| | |older people with dementia|2004 | |PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, |from 4) |cognition (at follow-up), mood (at |drawn are hampered by the |
| | |and their caregivers | | |plus Theses and on-going trials. Full | |follow-up), and on a measure of general|small number and |
| | | | | |details included in paper | |behavioural function (at end of |relatively low quality of |
| | | | | | | |intervention period). Improvement in |RCTs, as highlighted by |
| | | | | | | |cognition was evident in comparison |the authors. |
| | | | | | | |with both no treatment and social | |
| | | | | | | |contact conditions. However, of the | |
| | | | | | | |four RCTs included several were very | |
| | | | | | | |small studies, or were of relatively | |
| | | | | | | |low quality and each examined different| |
| | | | | | | |types of reminiscence work. More and | |
| | | | | | | |better designed trials are needed so | |
| | | | | | | |more robust conclusions may be drawn. | |
Table 13b. Reminiscence Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reminiscence Therapy
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |studies | | |
| |the review | | | | |reviewed | | |
|Livingston |+ |A systematic review of |Electronic |terms encompassing|Electronic databases; reference lists|5 |Assigned a grade |Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |individual |from individual and review articles, | |equivalent to troublingly |let down by lack of detail in search |
| | |to the management of |July 2003, Hand |dementias and |Cochrane Library plus hand searched | |inconsistent or |strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |interventions – no|three journals (titles not given) | |inconclusive studies. Of |replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10|further details | | |the three RCTs included |large number of papers included in the |
| | |of making evidence based |year period up to|given | | |one found a |review (162), other than highlighting |
| | |recommendations about the |July 2003 | | | |non-significant |the RCTs it is difficult to determine |
| | |use of these interventions| | | | |improvement when |study design or details such as sample |
| | | | | | | |reminiscence therapy was |characteristics or setting. |
| | | | | | | |preceded by reality | |
| | | | | | | |orientation but not vice | |
| | | | | | | |versa; the other found no | |
| | | | | | | |benefit | |
|Verkaik 2005 |+ |The effect of psychosocial|Search carried |Numerous terms |Pubmed, Cochrane CENTRAL/CCTR, |2 |One RCTof low quality |Overall a comprehensive review; however,|
| | |methods on depressed, |out from |included and |Cochrane Database of Systematic | |reports significantly |there is no discussion of the strength |
| | |aggressive and apathetic |September 2002 to|listed |Reviews, PsychINFO, EMBASE, CINAHL, | |lower self-reported |of evidence for no effect / negative |
| | |behaviours of people with |February 2003 | |INVERT, NIVEL, Cochrane Specialized | |depression at post-test |effect - only positive effect |
| | |dementia | | |Register, CDCIG, SIGLE, DARE. | |(but was higher than | |
| | | | | | | |control at baseline). | |
| | | | | | | | | |
Table 14a. Snoezelen Therapy/Multisensory Stimulation: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms |Databases searched |No of studies |Author’s Conclusions |Comments |
|Year |assessment of | | |used | |reviewed | | |
| |the review | | | | | | | |
|Chung 2002 |++ |What is the efficacy of|Original review |Trials |Specialised Register contained |3 papers |Overall no evidence for |A comprehensive update of a previous |
| | |snoezelen as a |2002; subsequent |identified from|records from : CENTRAL, MEDLINE, |representing two |efficacy of snoezelen for |review. |
| | |therapeutic |update 2004. No |the Specialised|EMBASE, PsycINFO, CINAHL, SIGLE, |trials (all RCTs) |dementia. There is a need for| |
| | |intervention for older |date exclusion |Register of the|ISTP, INSIDE, Aslib Index to | |more reliable and sound | |
| | |people with dementia? | |Cochrane |theses, Dissertation Abstract | |research-based evidence to | |
| | | | |Dementia and |(USA), | |inform and justify the use of| |
| | | | |Cognitive | |snoezelen in dementia care. | |
| | | | |Improvement |v/, National Research Register, | | | |
| | | | |Group using the|, LILACS, | | | |
| | | | |terms | | | |
| | | | |snoezelen, |m, , | | | |
| | | | |multi-sensory | | | |
| | | | | |, ISRCTN Register, IPFMA Clinical | | | |
| | | | | |Trials Register, Lundbeck Clinical| | | |
| | | | | |Trial Registry | | | |
|Lancioni 2002 |- |Examining |No details given |No details |PSYCLIT, Medical Express |21 but only 7 |Authors ‘tentative |Only PSYCLIT and Medical Express |
| | |within-session, | | | |relating to |considerations’: |databases were included in the |
| | |post-session and | | | |dementia |1. Snoezelen may have |computerised search. No details of |
| | |longer-term effects of | | | | |positive within-session |keywords used, numbers of papers |
| | |snoezelen with people | | | | |effects on stereotypes that |initially retrieved, |
| | |with developmental | | | | |are self-stimulatory in |inclusion/exclusion criteria, or |
| | |disabilities and | | | | |nature and on |process followed. |
| | |dementia | | | | |social/emotional behaviours |There is a very limited discussion of|
| | | | | | | |that are part of a withdrawal|study methodologies that is divorced |
| | | | | | | |condition in dementia |from the results and does not provide|
| | | | | | | |patients. |strong guidance on the interpretation|
| | | | | | | |2. Such positive effects |of results from individual studies. |
| | | | | | | |could be increased by |The poor literature search and |
| | | | | | | |choosing appropriate stimuli |inclusion of (presumably) low-quality|
| | | | | | | |for individual participants. |studies without significant |
| | | | | | | |3. Increasing within-session |discussion of this may result in |
| | | | | | | |positive effects may increase|effects being overstated |
| | | | | | | |post-session effects. | |
Table 14b. Snoezelen Therapy/Multisensory Stimulation: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Snoezelen Therapy/Multisensory Stimulation
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |snoezelen / | | |
| |the review | | | | |MSS studies | | |
| | | | | | |reviewed | | |
|Robinson 2006 |++ |To determine the clinical |Search carried |Full details of search |Included Cochrane Library, |3 |Some evidence, albeit of |Clear review with comprehensive |
|/ 2007 (two | |and cost effectiveness and|out up to and |terms contained in |MEDLINE, EMBASE, Central CINAHL,| |poor quality, for the |description of methodology, literature |
|papers on same| |acceptability of |including 31 |appendix |Social Science Citation Index, | |effectiveness of |and findings. The conclusions are in |
|study) | |non-pharmacological |March 2005 | |Science Citation Index, | |multi-sensory environment.|line with the findings. |
| | |interventions to reduce | | |PsycINFO, ADEAR, National | |Three RCTs; two did not | |
| | |wandering dementia | | |Research Register, ETHX atabase,| |provide evidence that a | |
| | | | | |Bioethicsweb, ISTP, ZETOC,, | |multisensory environment | |
| | | | | |Journal of Dementia Care | |effectively prevents | |
| | | | | |(1999-2004), Dementia (2002-4), | |wandering; the third | |
| | | | | |personal contact with | |provide no follow up | |
| | | | | |specialists in the field | |details and so the study | |
| | | | | | | |yielded no information | |
| | | | | | | |about effectiveness. | |
|Livingston |+ |A systematic review of |Electronic |terms encompassing |Electronic databases; reference |6 |Consistent evidence from |Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |individual dementias |lists from individual and review| |non-RCTs; the effects are |let down by lack of detail in search |
| | |to the management of |July 2003, Hand |and interventions – no |articles, Cochrane Library plus | |apparent for only very |strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |further details given |hand searched three journals | |short time after the |replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10| |(titles not given) | |session. Three RCTs; one |large number of papers included in the |
| | |of making evidence based |year period up to| | | |with no clear results; two|review (162), other than highlighting |
| | |recommendations about the |July 2003 | | | |found disruptive behaviour|the RCTs it is difficult to determine |
| | |use of these interventions| | | | |briefly improved outside |study design or details such as sample |
| | | | | | | |the treatment setting but |characteristics or setting. |
| | | | | | | |there was no effect after | |
| | | | | | | |the treatment stopped | |
Table 14b (cont). Snoezelen Therapy/Multisensory Stimulation: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Snoezelen Therapy/Multisensory Stimulation
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |snoezelen / | | |
| |the review | | | | |multi-sensor| | |
| | | | | | |y studies | | |
| | | | | | |reviewed | | |
|Verkaik 2005 |+ |The effect of psychosocial|Search carried |Numerous terms included|Pubmed, Cochrane CENTRAL/CCTR, |3 |There is some evidence |Overall a comprehensive review; however,|
| | |methods on depressed, |out from |and listed |Cochrane Database of Systematic | |(from 2 high quality RCTs)|there is no discussion of the strength |
| | |aggressive and apathetic |September 2002 to| |Reviews, PsychINFO, EMBASE, | |that multi-sensory |of evidence for no effect / negative |
| | |behaviours of people with |February 2003 | |CINAHL, INVERT, NIVEL, Cochrane | |stimulation/Snoezelen in a|effect - only positive effect |
| | |dementia | | |Specialized Register, CDCIG, | |multi-sensory room reduces| |
| | | | | |SIGLE, DARE. | |apathy in people in the | |
| | | | | | | |latter stages of dementia.| |
|Cohen-Mansfiel|- |Considers inappropriate |No dates given |No details given |PsycLIT, MEDLINE, and a nursing |4 |Most studies report |The volume of studies included in the |
|d 2001 | |behaviours in dementia; a | | |subset of MEDLINE | |improvement though it is |overall review (n=83) mean that some, |
| | |literature search on the | | | | |not necessarily |but not all of the studies are |
| | |impact of | | | | |statistically significant |described, but all are given equal |
| | |non-pharmacological | | | | | |weight. Methodological issues are |
| | |interventions (to address | | | | | |presented within the discussion section,|
| | |the issues of | | | | | |these relate to diverse measurement |
| | |understanding of the | | | | | |methods, criteria for success, screening|
| | |interventions, their | | | | | |procedures, control procedures and |
| | |effects and their | | | | | |treatment of failures. Little or no |
| | |feasibility) | | | | | |account is taken of study design (RCT, |
| | | | | | | | |case study etc). |
Table 15. TENS: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |exercise | | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Cameron 2003 |++ |To determine the |Up to December |TENS, ‘transcutaneous |Specialised Register contained |9 (of which |TENS produced a |A comprehensive and well designed |
| | |effectiveness and safety |2005 |electrical nerve |records from : CENTRAL, MEDLINE,|3 included |statistically significant |review. The review suggests the |
| | |of TENS in the treatment | |stimulation’ |EMBASE, PsycINFO, CINAHL, SIGLE,|in meta |improvement directly after|potential benefits of TENS for people |
| | |of dementia | |‘electrical |ISTP, INSIDE, plus Theses and |analysis) |treatment in delayed |with dementia. The studies included |
| | | | |stimulation’ ‘cranial |on-going trials. Full details | |recall in one trial, face |demonstrated consistency in |
| | | | |electrostimulation’ |included in paper | |recognition in two trials |experimental designs, subjects, |
| | | | |‘cranial stimulation’ | | |and motivation in one |interventions and outcome measures but |
| | | | | | | |trial. No effect on the |unfortunately only three could be used |
| | | | | | | |other neuropsychological |in the meta-analysis. As suggested by |
| | | | | | | |and behaviour measures |the authors to increase the |
| | | | | | | |either directly after or 6|generalisability of the findings to a |
| | | | | | | |weeks after treatment/ |wider population the work be replicated |
| | | | | | | |Authors conclude: TENS may|in a larger group of individuals. |
| | | | | | | |produce in some | |
| | | | | | | |neuropsychological or | |
| | | | | | | |behavioural aspects of | |
| | | | | | | |dementia. The limited | |
| | | | | | | |presentation and | |
| | | | | | | |availability of data from | |
| | | | | | | |these studies does not | |
| | | | | | | |allow definite conclusions| |
| | | | | | | |on possible benefits. Re | |
| | | | | | | |safety: although unlikely | |
| | | | | | | |to have adverse effects, | |
| | | | | | | |insufficient data to | |
| | | | | | | |recommend use. | |
Table 16a. Validation Therapy: Key Characteristics of included systematic reviews (including at least one RCT).
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |exercise | | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Neal 2003 |++ |What is the efficacy of |Search carried |Validation therapy, |Specialised Register contained |3 (all RCTs)|All in all there is |Clear review with comprehensive |
| | |validation therapy, |out August 2005. |VDT, emotion oriented |records from : CENTRAL, MEDLINE,| |insufficient evidence from|description of methodology, literature |
| | |offered in group or |No date exclusion|care |EMBASE, PsycINFO, CINAHL, SIGLE,| |randomised trials to allow|and findings. The conclusions are in |
| | |individual format, as an | | |ISTP, INSIDE, Aslib Index to | |any conclusion about the |line with the findings however, it |
| | |intervention for patients | | |theses, Dissertation Abstract | |efficacy of validation |should be noted that the authors report |
| | |with dementia or cognitive| | |(USA), | |therapy for people with |a lack of clarity regarding whether |
| | |impairment? | | | |dementia or cognitive |participants have dementia. |
| | | | | |gov/, National Research | |impairment | |
| | | | | |Register, , | | | |
| | | | | |LILACS, | | | |
| | | | | | | | |
| | | | | |com, , | | | |
| | | | | | | | |
| | | | | |ml, ISRCTN Register | | | |
Table 16b. Validation Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Validation Therapy
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of |Author’s Conclusions |Comments |
|Year |assessment of| | | | |exercise | | |
| |the review | | | | |studies | | |
| | | | | | |reviewed | | |
|Livingston |+ |A systematic review of |Electronic |terms encompassing |Electronic databases; reference |3 |No conclusive evidence. |Overall a comprehensive review that is |
|2005 | |psychological approaches |database up to |individual dementias |lists from individual and review| |Only one RCT comparing |let down by lack of detail in search |
| | |to the management of |July 2003, Hand |and interventions – no |articles, Cochrane Library plus | |validation therapy to |strategy which means it is not |
| | |neuropsychiatric symptoms |searched three |further details given |hand searched three journals | |usual care or a social |replicable. In addition, due to the very|
| | |of dementia with the aim |journal during 10| |(titles not given) | |contact group. No |large number of papers included in the |
| | |of making evidence based |year period up to| | | |difference was found in |review (162), other than highlighting |
| | |recommendations about the |July 2003 | | | |independent outcome |the RCTs it is difficult to determine |
| | |use of these interventions| | | | |ratings, nursing time |study design or details such as sample |
| | | | | | | |needed or in use of |characteristics or setting. |
| | | | | | | |psychotropic medication | |
| | | | | | | |and restraint | |
|Verkaik 2005 |+ |The effect of psychosocial|Search carried |Numerous terms included|Pubmed, Cochrane CENTRAL/CCTR, |4 |No or insufficient |Overall a comprehensive review; however,|
| | |methods on depressed, |out from |and listed |Cochrane Database of Systematic | |evidence. |there is no discussion of the strength |
| | |aggressive and apathetic |September 2002 to| |Reviews, PsychINFO, EMBASE, | |3 studies found no |of evidence for no effect / negative |
| | |behaviours of people with |February 2003 | |CINAHL, INVERT, NIVEL, Cochrane | |significant changes in |effect - only positive effect |
| | |dementia | | |Specialized Register, CDCIG, | |apathy, aggression or | |
| | | | | |SIGLE, DARE. | |depression. The fourth | |
| | | | | | | |found a significant | |
| | | | | | | |change in depression after| |
| | | | | | | |1 year compared with | |
| | | | | | | |alternate therapy but not | |
| | | | | | | |usual care group. | |
Table 17. Characteristics of included systematic reviews that did not identify any studies for inclusion
|Author, |Overall |Research Question |Years covered |Search terms used |Databases searched |No of studies |Author’s Conclusions|Comments |
|Year |assessment of| | | | |reviewed | | |
| |the review | | | | | | | |
|Herman 2007 |++ |Evaluating the |Search conducted |Exit*, wander* or |Specialised Register contained records from :|0 |N/A |N/A. |
| | |effectiveness and safety |May 2006. No |elopement or ambulat* |CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, | | | |
| | |of non-pharma |explicit date |or walk* |SIGLE, ISTP, INSIDE, Aslib Index to theses, | | | |
| | |interventions in reducing |exclusion | |Dissertation Abstract (USA), LILACS, | | | |
| | |wandering in domestic | | |, | | | |
| | |settings | | |National Research Register, | | | |
| | | | | |, | | | |
| | | | | |, | | | |
| | | | | |, | | | |
| | | | | |, ISRCTN | | | |
| | | | | |Register, IPFMA Lundbeck Clinical Trial | | | |
| | | | | |Register | | | |
|Peng 2007 |++ |What is the efficacy and |Search carried |Acupunc* |Specialised Register contained records from :|0 |N/A |N/A |
| | |possible adverse effects |out February | |CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, | | | |
| | |of acupuncture therapy for|2007. No date | |SIGLE, LILACS, plus conference proceedings, | | | |
| | |treating vascular |exclusion | |theses and on-going trials | | | |
| | |dementia? | | | | | | |
|Price 2001 |++ |To review non-drug / |Search carried |Exit*, wander*, |Specialised Register contained records from :|0 |N/A |N/A |
| | |non-physical barriers to |out January 2007 |camouflage, bars, |CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, | | | |
| | |reduce wandering in people| |stripe*, grid*, floor*,|SIGLE, LILACS, plus conference proceedings, | | | |
| | |with acquired cognitive | |door*, barrier*, |theses and on-going trials | | | |
| | |impairment | |elopement, ambulat* | | | | |
Matrix 2a. Aggression
| Strategy |Activities to relieve boredom / distract |
| | |
| | |
| | |
| | |
|Organsiation | |
|Guideline topic |Key question no: |
|Checklist completed by: |
|SECTION 1: INTERNAL VALIDITY |
|In a well-conducted systematic review: |In this study this criterion is: |
| |(Circle one option for each question) |
|1.1 |The study addresses an appropriate and clearly focused |Well covered Not addressed |
| |question. |Adequately addressed Not reported |
| | |Poorly addressed Not applicable |
|1.2 |A description of the methodology used is included. |Well covered Not addressed |
| | |Adequately addressed Not reported |
| | |Poorly addressed Not applicable |
|1.3 |The literature search is sufficiently rigorous to identify|Well covered Not addressed |
| |all the relevant studies. |Adequately addressed Not reported |
| | |Poorly addressed Not applicable |
|1.4 |Study quality is assessed and taken into account. |Well covered Not addressed |
| | |Adequately addressed Not reported |
| | |Poorly addressed Not applicable |
|1.5 |There are enough similarities between the studies selected|Well covered Not addressed |
| |to make combining them reasonable. |Adequately addressed Not reported |
| | |Poorly addressed Not applicable |
|SECTION 2: OVERALL ASESSMENT OF THE STUDY |
|2.1 |How well was the study done to minimise bias? Code ++, + | |
| |or - | |
|2.2 |If coded as + or – what is the likely direction in which | |
| |bias might affect the study results? | |
|SECTION 3: DESCRIPTION OF THE STUDY Please print answers clearly |
|3.1 |What types of study are included in the review?|RCT CCT Cohort |
| |(Highlight all that apply) | |
| | |Case-control Other |
|3.2 |How does this review help to answer your key | |
| |question? | |
| |Summarise the main conclusion of the review and| |
| |how it related to the relevant key question. | |
| |Comment on any particular strengths or | |
| |weaknesses of the review | |
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