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Acupuncture

VIEWS: 57 PAGES: 171

									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
Charles Thackrah Building
University of Leeds
101 Clarendon Road
Leeds, United Kingdom
LS2 9LJ

www.leeds.ac.uk/lihs
                                       2


                                 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

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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

                                                 Leeds Institute of Health Sciences
                                                                          July 2008
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                                  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 diseases1. 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 themselves2.


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



1 http://www.publications.parliament.uk/pa/cm200708/cmselect/cmpubacc/228/228.pdf


2 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=546




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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.




                                               Leeds Institute of Health Sciences
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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


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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 stages3


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.




3 http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE


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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)

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                     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



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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


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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 "




                                               Leeds Institute of Health Sciences
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                                           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 dementia4.                          It is a
progressive and eventually fatal disease (Yuhas et al, 2006, p35) of unknown
etiology with characteristic neuropathological and neurochemical features5. 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


4
    http://www.patient.co.uk/showdoc/23068719/
5
    http://www.who.int/classifications/apps/icd/icd10online/

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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).

6   http://www.who.int/classifications/apps/icd/icd10online/


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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).




                                                 Leeds Institute of Health Sciences
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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 carers8 deliver
most of the care to people with dementia in the UK and many are elderly and
frail themselves9. A National Dementia Strategy is planned for 200810.


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?



7
    http://www.publications.parliament.uk/pa/cm200708/cmselect/cmpubacc/228/228.pdf
8
 Informal carers are people who look after a relative or friend who needs support because of
age, physical or learning disability or illness, including mental illness.
9 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=546
10 http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Olderpeoplesservices/DH_077211




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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


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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.




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Box 1: Reasons for Exclusion from the Review
Not systematic reviews only (not reviews) including at least          57
one randomised controlled trial of a non-drug intervention
Not English language                                                  4
The primary purpose of the review is not to evaluate the              6
effectiveness or efficacy evidence of one or 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

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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) http://www.alzheimers.org.uk/site/
      Alzheimer’s Association (USA) http://www.alz.org/index.asp
      Alzheimer’s Australia (Australia) http://www.alzheimers.org.au/index.cfm
      Alzheimer Europe http://www.alzheimer-europe.org/




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                              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




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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
behaviour11. 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                   Behavioural and
                                     activities of daily              psychological symptoms
                                           living
     Cognitive Function              Functional Ability                    Aggression
      Communication                 Quality of Life/Well-                   Agitation
         Learning                           being                            Anxiety
         Memory                                                              Apathy
           Recall                                                           Behaviour
                                                                           Depression
                                                                    Emotional and Behavioural
                                                                            Responses
                                                                     Inappropriate Behaviour
                                                                              Mood
                                                                    Neuropsychiatric Symptoms
                                                                            Nutrition
                                                                     Psychological Symptoms
                                                                               Sleep
                                                                         Social Behaviour
                                                                           Wandering



11
     http://www.searo.who.int/en/Section1174/Section1199/Section1567/Section1823_8057.htm



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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           Behavioural and
                          activities of daily living       psychological
                                                             symptoms
        Cognitive            Cognitive Stimulation          Animal Assisted
       Stimulation            Therapy/Cognitive                 Therapy
   Therapy/Cognitive               Training                  Aromatherapy
        Training                   Physical                    Behaviour
       Counselling             Activity/Exercise             Management
     Light Therapy            Reality Orientation              Cognitive
      Music/Music              Snoezelen/Multi-               Stimulation
         Therapy              sensory Stimulation         Therapy/Cognitive
         Physical                                               Training
    Activity/Exercise                                       Environmental
   Reality Orientation                                       Manipulation
      Reminiscence                                           Light Therapy
         Therapy                                            Massage/Touch
    Snoezelen/Multi-                                         Music/Music
         sensory                                                Therapy
       Stimulation                                              Physical
          TENS                                             Activity/Exercise
   Validation Therapy                                     Reality Orientation
                                                             Reminiscence
                                                                Therapy
                                                           Snoezelen/Multi-
                                                          sensory Stimulation
                                                                 TENS
                                                          Validation Therapy




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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 three13.
Only one review was identified that attempted to explore the use of




12
     http://www.acupuncture.org.uk/content/AboutAcupuncture/acupuncture.html
13   http://www.medical-acupuncture.co.uk/patients/

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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 time14. 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 individual15.




14
     http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1
15   http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1

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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

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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.




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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 ways16. 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.

16
     http://www.aromatherapycouncil.co.uk/index_files/Page390.htm

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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.




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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.



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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.




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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 area17.


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.



17
     http://www.sign.ac.uk/pdf/sign86.pdf

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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

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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


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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.




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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


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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


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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
conditions18. 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.

18
     http://www.columbia.edu/~mt12/blt.htm

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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

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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


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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

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       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 music19. Approaches to music therapy differ but key
to all is the development of a relationship between client and therapist20.
Music therapy typically includes one or more of the following: listening,
singing or playing; the process may take place in individual or group
sessions21.


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,

19
   http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=90&pageNumber=1
20
   http://www.bsmt.org/what_is_mt.htm
21
   http://www.bsmt.org/what_is_mt.htm


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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


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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

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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.

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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

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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



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      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:



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     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

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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




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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

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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




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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

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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,


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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

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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

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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.




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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


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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 individuals22.
The techniques of validation are simple to learn and can be performed within
the course of a typical day23. 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


22
     http://www.vfvalidation.org/whatis.html
23

http://academic.evergreen.edu/curricular/hhd2000/Mukti's%20Notes/VALIDATION%20THERAPY.ht
m

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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

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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).




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                              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


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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 tomorrow24. 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
illness25.


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 three26. 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 (http://www.medical-
acupuncture.co.uk/) or The British Complementary Medicine Association
(http://www.bcma.co.uk/).

24
   www.alzheimer-europe.org/pages/print_article.php?idart=8E3C2105BDFD
25
   http://www.alzheimers.org.au/content.cfm?infopageid=4025#why
26
   http://www.medical-acupuncture.co.uk/patients/

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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
guidelines28, 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 needs29. 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 environment30 that can contribute to the well-being of the person


27
   http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1
28
   http://www.nice.org.uk/nicemedia/pdf/CG042NICEGuideline.pdf
29
   http://www.alzheimers.org.uk/downloads/Dementia_SH_comments_formAlzSoc.pdf
30   http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


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being cared (Wilson & Turner, 1998). Pets have also been shown to reduce
depression and boost self-esteem31. 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 mobile33.


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.




31 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp
32 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1
33 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp




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          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
distraction35
          When becoming confused, restless or insecure the person with
dementia may be comforted by the presence of a pet36
          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 contact37.


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 powers38. The essential oils, extracted from
plants, are applied in a variety of ways including directly to the skin through




34 http://www.alzheimers.org.uk/factsheet/505
35 http://www.alzheimers.org.uk/factsheet/525
36http://www.alzheimers.org.au/upload/HS5.5.pdf
37 http://www.alzheimers.org.au/upload/HS2.5.pdf
38
     http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271

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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 use40.


Oils should be diluted according to the instructions before being applied to
the skin41 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 smell42.
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




39 http://www.aromatherapycouncil.co.uk/index_files/Page390.htm
40 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=307&pageNumber=2
41 http://www.alzheimers.org.uk/downloads/non_pharmacological_therapies.pdf


42 http://www.alzheimers.org.uk/factsheet/505




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lavender oil to a bath43 or giving a hand massage, again using a scented oil
such as lavender44.


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 shows45.



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 on46. The
person being cared for may enjoy hand, neck and foot massage47, 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.




43 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


44 http://www.alzheimers.org.uk/factsheet/505.
45 http://www.alzheimers.org.au/upload/HS2.5.pdf
46 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=420&pageNumber=1
47 http://www.alzheimers.org.au/upload/HS2.5.pdf


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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 right48.


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 them49. Similarly, in coping with
hallucinations, touching and talking in a calm and reassuring way may bring
the person back to reality50 and gentle patting might distract the person’s
attention and reduce the hallucination51. 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 nervous52 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




48 http://www.alzheimers.org.uk/factsheet/505
49http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=7E655C216B76


50 http://www.alzheimer-europe.org/index.php?lm3=AE2B78339B97&sh=9367AE810697


51 http://www.alz.org/national/documents/topicsheet_hallucinations.pdf
52   http://www.alzheimer-europe.org/pages/print_article.php?idart=C3448C7AFDFE


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as talking, hand holding, or gentle massage53. 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 massage54 or brushing the person’s hair
        When becoming confused, restless or insecure the person with
dementia may find a back rub calming55
        For those people being cared for who are depressed try more one-to-
one interaction, such as talking, hand holding, or gentle massage, if
appropriate56.
        Where the person may do or say something over and over again
(repetition) reassure them with a calm voice and gentle touch57.
        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


53 http://www.alzheimers.org.uk/factsheet/444
54 http://www.alzheimers.org.uk/factsheet/525
55http://www.alzheimers.org.au/upload/HS5.5.pdf
56http://www.alzheimers.org.uk/factsheet/444
57 http://www.alz.org/living_with_alzheimers_repetition.asp


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help bring the person back to reality58. Gentle patting might distract the
person’s attention and reduce the hallucination59.
          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 area60. 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.




58 http://www.alzheimer-europe.org/index.php?lm3=AE2B78339B97&sh=9367AE810697


59 http://www.alz.org/national/documents/topicsheet_hallucinations.pdf

60
     http://www.sign.ac.uk/pdf/sign86.pdf

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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.



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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 stages61 .


For carers wishing to access counselling services accredited practitioners may
be found through The British Association for Counselling and Psychotherapy
(http://www.bacp.co.uk/).


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

61
     http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE

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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 conditions62) 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 sleep63; whilst the Alzheimer’s
Association recommend seeking morning sunlight exposure to improve sleep
routines64.


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


62
   http://www.columbia.edu/~mt12/blt.htm
63
   http://www.alzheimers.org.uk/downloads/non_pharmacological_therapies.pdf
64
   http://www.alz.org/alzheimers_disease_10429.asp

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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 radio65.


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 dementia66 and
can even result in hallucinations, where the person with dementia can see
things that do not exist for example, misinterpreting shadows as black holes67.
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 reflection69. 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 room70.


Sleeplessness may be a problem. Sleep is thought to be aided by use of
nightlights in the bedroom. A radio playing softly may also help71; and if
waking up during the night is a problem, nightlights may help the person




65   http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=68634710EEE1
66 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
67 http://www.alzheimers.org.au/upload/HS5.9.pdf
68
     http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271
69 http://www.alz.org/national/documents/topicsheet_hallucinations.pdf.
70 http://www.alz.org/living_with_alzheimers_bathing.asp
71
     http://www.alzheimers.org.au/upload/HS5.5.pdf

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with dementia recognise where they are when they wake up 72 providing
reassurance and potentially reducing occurrences of shouting or screaming at
night73. 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
something74. 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
agitated75. 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 stimulating76. 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


72 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
73 http://www.alzheimers.org.uk/factsheet/525
74 http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=CE9A3B723109
75 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
76 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


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Music and Music Therapy
Even when other abilities are seriously affected people may still enjoy
singing, dancing and listening to music77. 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
http://www.nordoff-robbins.org.uk/or 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 time78.


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


77
   http://www.alzheimers.org.uk/factsheet/505
78
   http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271
79
   http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271

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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 adult82; 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 enjoyment83. Singing can have a
significant calming effect on some people; Alzheimer’s Australia suggest
singing favourite songs or soothing lullabies84.


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 music85. 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
alone86. Similarly, for those who can become agitated whilst bathing try
playing soothing music or singing together87.


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


80 http://www.alzheimers.org.au/content.cfm?infopageid=4187
81 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp#2
82 http://www.alzheimers.org.au/content.cfm?infopageid=4187
83 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp#2
84 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
85 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
86 http://www.alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200208&documentID=365
87 http://www.alz.org/living_with_alzheimers_bathing.asp


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again and provide reassurance88. 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 memories89. Similarly
sensory overload can be minimised by eliminate competing noises. Try
shutting windows and doors and turning off the television90. Music might
also be used as sleep inducing strategy either by playing soothing music 91 or
by having a radio playing softly92. 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




88 http://www.alzheimers.org.au/content.cfm?infopageid=4187
89 http://www.alzheimers.org.au/content.cfm?infopageid=4187
90 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp#2
91 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
92 http://www.alzheimers.org.au/upload/HS5.5.pdf




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                    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


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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 depression93, may help prevent outbursts of aggression94, anxiety, and
agitation and improve appetite and sleep. Physical exercise or activities can
also provide a distraction from hallucinations95 and can reduce wandering
through alleviating boredom and using up spare energy96.


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 night97.


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




93 http://www.alzheimers.org.au/upload/Depression.pdf
94http://www.alzheimers.org.au/upload/HS5.1.pdf
95 http://www.alzheimers.org.au/upload/HS5.9.pdf
96 http://www.alzheimers.org.uk/factsheet/501
97 http://www.alzheimers.org.uk/factsheet/505


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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 calming98, 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 well99. 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 shops100, walking
to places locally rather than driving or walking the dog together101. Walking
can have a very calming effect on some people102 and short walks can be
incorporated into daily routines as a pleasurable activity that the person with
dementia can enjoy103.


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 table104. Helping with household chores can provide
the person with dementia with a sense of purpose and boost their self esteem;


98 http://www.alzheimers.org.uk/factsheet/505
99 http://www.alzheimers.org.au/upload/HS2.5.pdf
100 http://www.alzheimers.org.uk/factsheet/505
101 http://www.alzheimers.org.au/upload/HS2.5.pdf
102 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
103 http://www.alzheimers.org.uk/factsheet/444
104 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-
europe.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107


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it can also add structure to the day and is a way to do something together
with the carer105.


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 frustrated106. 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 depression107, may help prevent
outbursts of aggression108, anxiety, agitation and improve appetite and sleep.
Physical exercise or activities can also provide a distraction from
hallucinations109 and can reduce wandering through alleviating boredom and
using up spare energy110.
        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




105 http://www.alzheimer-europe.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107
106 http://www.alzheimer-europe.org/index.php?lm3=BF4E655E2855&sh=F110C4B8AE93
107 http://www.alzheimers.org.au/upload/Depression.pdf
108http://www.alzheimers.org.au/upload/HS5.1.pdf
109 http://www.alzheimers.org.au/upload/HS5.9.pdf
110 http://www.alzheimers.org.uk/factsheet/501


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       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 table111.


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 incorrect112. 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.




111 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-
europe.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107
112
    http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6

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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 care113.


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 interested114. 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,




113 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6


114 http://www.alzheimers.org.uk/factsheet/505


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and show them that you understand115. If their distress seems overwhelming then
it might be better to switch to another form of activity116.


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 music117.
        If reading skills have deteriorated make individual audiotapes118.
        Locate picture books and magazines in the person’s areas of interest119.
        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 pictures120
        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 page121



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


115 http://www.alzheimers.org.uk/factsheet/526


116 http://www.alzheimers.org.au/content.cfm?infopageid=4524


117 http://www.alzheimers.org.uk/factsheet/505


118 http://www.alzheimers.org.au/upload/HS2.5.pdf
119 http://www.alzheimers.org.au/upload/HS2.5.pdf


120 http://www.alzheimers.org.uk/factsheet/505


121 http://www.alzheimers.org.au/content.cfm?infopageid=4524


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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 feel122. 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


122 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6




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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
individuals123. 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 anxiety124. 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 maintained126,127


It is suggested that the techniques of validation are simple to learn and can be
performed within the course of a typical day128. 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



123   http://www.vfvalidation.org/whatis.html
124 http://www.alzheimers.org.au/content.cfm?infopageid=4524#val
125 http://www.alzheimers.org.uk/factsheet/500
126 http://www.alzheimers.org.uk/factsheet/500
127 http://www.alzheimers.org.au/content.cfm?infopageid=4524#val
128 http://academic.evergreen.edu/curricular/hhd2000/Mukti's%20Notes/VALIDATION%20THERAPY.htm


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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 dementia129; 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 critical130. 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 arguing131.


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 say132. Similarly in coping with



129 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6

130 http://www.alzheimers.org.uk/factsheet/526
131 http://www.alzheimer-europe.org/index.php?lm3=2910C4678344&sh=ECE3B9A63711
132 http://www.alzheimer-europe.org/index.php?lm3=2910C4678344&sh=ECE3B9A63711


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wandering try not correcting the person when he or she says that they wants
to leave to go to work or home133.


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


133 http://www.alz.org/national/documents/topicsheet_wandering.pdf



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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 glare134. 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




134
      http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf

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        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 appropriate135
        Provide reassurance or encouragement talking with a calm voice and
         gentle touch136
        Touch is very important; try giving the person being cared for a hand
         massage137, 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


135http://www.alzheimers.org.uk/factsheet/444
136 http://www.alz.org/living_with_alzheimers_repetition.asp
137 http://www.alzheimers.org.uk/factsheet/525


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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

138 http://www.alzheimers.org.uk/factsheet/505


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                          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
distraction139; 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 contact140.


Sensory stimulation
        Touch is very important:
                          Try using a hand massage141, 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 appropriate142.
                          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

139 http://www.alzheimers.org.uk/factsheet/525
140 http://www.alzheimers.org.au/upload/HS2.5.pdf
141 http://www.alzheimers.org.uk/factsheet/525
142http://www.alzheimers.org.uk/factsheet/444


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        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
                           table143.


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 music144.
                          If reading skills have deteriorated make individual
                           audiotapes145
                          Locate picture books and magazines in the person’s areas
                           of interest146



143 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-
europe.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107


144 http://www.alzheimers.org.uk/factsheet/505


145 http://www.alzheimers.org.au/upload/HS2.5.pdf
146 http://www.alzheimers.org.au/upload/HS2.5.pdf


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                          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 pictures147
                          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 page148


Aggression
Aggression may manifest itself either verbally (shouting, name-calling) or
physically (hitting, pushing) and can occur very suddenly149. It may be caused
by hallucinations150, anxiety, fear, agitation, nervousness, anger and
frustration151 or by low levels of physical activity152. 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
down153.


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



147 http://www.alzheimers.org.uk/factsheet/505


148 http://www.alzheimers.org.au/content.cfm?infopageid=4524
149 http://www.alz.org/living_with_alzheimers_aggression.asp
150 http://www.alzheimers.org.au/content.cfm?infopageid=4514
151 http://www.alzheimer-europe.org/index.php?lm3=6761D7E11104&sh=6C43BEDD7AAD
152 http://www.alzheimers.org.au/upload/HS5.1.pdf
153 http://www.alzheimer-europe.org/index.php?content=showarticle&lm3=6761D7E11104


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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 http://www.nordoff-robbins.org.uk/or 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 time154.
          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 them155. Take care that the touch is not



154
      http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271
155http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=7E655C216B76


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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
behaviour156 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 room157. 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 bath158 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 screaming159. Causes include lack of sleep or disruptive sleep
patterns, physical discomfort, medication, and hallucination160




156http://www.alzheimers.org.au/upload/HS5.1.pdf
157 http://www.alz.org/living_with_alzheimers_bathing.asp


158 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


159
      http://www.alzheimers.org.au/content.cfm?infopageid=4515
160
      http://www.alzheimers.org.au/content.cfm?infopageid=4515

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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 http://www.nordoff-robbins.org.uk/or 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 agitation161



161 http://www.alzheimers.org.uk/factsheet/525


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         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
bath162
         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 hallucinations164. (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




162 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


163 http://www.alzheimers.org.uk/factsheet/525
164 http://www.alzheimers.org.au/upload/HS5.9.pdf


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                            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 hopelessness165. 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.


165
      http://www.alz.org/living_with_alzheimers_depression.asp

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      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 http://www.nordoff-robbins.org.uk/or 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

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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 day167
          Try more one-to-one interaction, such as talking, hand holding, or
gentle massage, if appropriate168.
          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




166 http://www.alzheimers.org.au/upload/HS2.5.pdf
167
      http://www.alzheimers.org.au/content.cfm?infopageid=4464
168http://www.alzheimers.org.uk/factsheet/444


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                            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 felt169. 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   http://www.nordoff-
robbins.org.uk/or 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


169
      http://www.alz.org/living_with_alzheimers_hallucinations.asp

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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 massage170 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 reality171.
        Gentle patting might distract the person’s attention and reduce the
hallucination172.
        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


170 http://www.alzheimers.org.uk/factsheet/525


171 http://www.alzheimer-europe.org/index.php?lm3=AE2B78339B97&sh=9367AE810697


172 http://www.alz.org/national/documents/topicsheet_hallucinations.pdf


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                          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 music173 or by having a radio playing softly
       Boredom can be addressed using a range of activities (see activities
subsection)



173 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


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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 pain174. It may be the result of stress or
anxiety or the side effects of medication175 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 http://www.nordoff-robbins.org.uk/or 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 time176.




174
      http://www.alzheimers.org.au/content.cfm?infopageid=4465
175
       http://www.alz.org/living_with_alzheimers_wandering_behaviors.asp
176
      http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271

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         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 music177 or by having a radio playing
softly.




177 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf


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                                 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

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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.




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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 stages178


         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

178
      http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE

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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)



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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.



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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.




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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-     Depression   Emotional     Functional   Inappropriate   Learning   Memory
                                                                         Function    cation                    &             Ability      behaviour
                                                                                                               Behavioural
                                                                                                               Responses
 Acupuncture
  (no studies
   included)
    Animal           2           2
    Assisted
    Therapy
Aromatherapy                     2
  Behaviour          2                                2                                               2
Management
   Cognitive                                                    2           2                         2                                                                 2
 stimulation /
rehabilitation
   / training
 Counselling                                                                                                                                                     1      1
Environment                      2                                                                                                             2
Manipulation
Light Therapy                    2                              2           2
  Massage /          2           0          2
    Touch
Music / music        0           0                              0           0                                      0
   therapy
   Physical                      2                                          2                                                    2
   activity /
   exercise
    Reality                                           2         1           2           1             2                          1
 orientation
Reminiscence                                          2         2           2                         2
   therapy
 Snoezelen /         2                                2         2           2           1             2            2             2
multi-sensory
 stimulation
    TENS                                                        2           2                                                                                           2
 Validation          1                                1         2           1                         2            2
  therapy




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Matrix 1b. Interventions and Symptoms: 0=Evidence of effectiveness; 1= No evidence of effectiveness; 2=inconclusive evidence
                      Mood   Neuropsychiatric   Nutrition   Psychological   Quality of Life /         Recall   Sleep   Social      Wandering
                             Symptoms                        Symptoms         Well-being                               Behaviour
  Acupuncture

 Animal Assisted                                   2                                                                        2
    Therapy
 Aromatherapy                       2                                                                                                     2
   Behaviour                        2                                                                                                     1
  Management
    Cognitive                       2                                              2
  stimulation /
 rehabilitation /
     training
  Counselling                                                                                           1
  Environment                                                                                                                             2
  Manipulation
  Light Therapy        2                                         2                                                2
 Massage / Touch                                   0                                                                                      2
  Music / music                                    0             0                                                          0             0
     therapy
Physical activity /    0                                                                                          0                       0
     exercise
Reality orientation                                                                1
  Reminiscence         2
     therapy
Snoezelen / multi-     1                           2                                                                        2             2
      sensory
   stimulation
       TENS

    Validation                      2
     therapy




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Table 1. Acupuncture: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included




  Author,        Overall      Research Question        Years         Search terms        Databases searched          No of       Author’s Conclusions on          Comments
   Year        assessment                             covered            used                                       studies        Counselling Study
                  of the                                                                                           reviewed
                 review
 Peng 2007         ++         What is the efficacy     Search         Acupunct*          Specialised Register          0           There is currently no      Clear search criteria
                                 and possible        carried out                       contained records from :                   evidence available from
                               adverse effects of     February                          CENTRAL, MEDLINE,                         sufficiently high quality
                                 acupuncture          2007. No                           EMBASE, PsycINFO,                       RCTs to allow assessment
                              therapy for treating    details of                           CINAHL, SIGLE,                             of the efficacy of
                              vascular dementia?         date                           LILACS, ISTP, INSIDE,                        acupuncture in the
                                                     restrictions                        plus these, on-going                      treatment of vascular
                                                                                                 trials                                   dementia




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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         No of            Author’s Conclusions                         Comments
  Year       assessme                                                                     searched         studies
             nt of the                                                                                    reviewed
              review
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
                           have investigated                        therapy, pet and      PsychInfo,                     psychosocial intervention for            were identified originally or
                          whether AAT has a                            dementia           CINAHL                          people with dementia. The                     screening criteria
                         measurable beneficial                                                                        optimal frequencies and duration         Some aspects of study design not
                         effect for people with                                                                         of AAT sessions, as well as the       clear – for example randomisation;
                             dementia and                                                                              optimal format of such sessions,           small sample sizes, selection
                            specifically upon                                                                               need systematic study.              criteria is likely to overestimate
                            behavioural and                                                                                                                                    results
                             psychological                                                                              Studies considered a number of
                              symptoms of                                                                             interventions including ‘pet visits’,
                                dementia                                                                              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




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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        No of            Author’s Conclusions                        Comments
  Year       assessme                                                                   searched         AAT
             nt of the                                                                                  studies
              review                                                                                   reviewed
 Cohen-          -             Considers            No dates       No details given      PsycLIT,          83        Pet therapy: 3 studies, all report    The volume of studies included in
Mansfield                    inappropriate           given                              MEDLINE,                              improvements                the overall review mean that some,
  2001                       behaviours in                                             and a nursing                                                           but not all of the studies are
                         dementia; a literature                                          subset of                                                         described, but all are given equal
                         search on the impact                                           MEDLINE                                                            weight. Methodological issues are
                                 of non-                                                                                                                     presented within the discussion
                           pharmacological                                                                                                                    section, these relate to diverse
                           interventions (to                                                                                                              measurement methods, criteria for
                         address the issues of                                                                                                                success, screening procedures,
                         understanding of the                                                                                                              control procedures and treatment
                          interventions, their                                                                                                             of failures. Little or no account is
                            effects and their                                                                                                               taken of study design (RCT, case
                               feasibility)                                                                                                                              study etc).




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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                        Comments
  Year       assessme                                                                                                      studies        Conclusions
             nt of the                                                                                                    reviewed
              review
Thorgrims       ++        What is the evidence    Search carried        Aroma*,                Specialised Register        2 (all         The additional        Clear review with comprehensive
en 2003 /                  for the efficacy of    out April 2006     complementary          contained records from :       RCTs)     analyses (of only one        description of methodology,
2006 (two                 aromatherapy as an                       therap*, alternative      CENTRAL, MEDLINE,                          RCT) conducted             literature and findings. The
  papers                    intervention for                        therap*, essential        EMBASE, PsycINFO,                      revealed a statistically    conclusions are in line with the
reporting                     people with                                  oil*              CINAHL, SIGLE, ISTP,                     significant treatment                  findings.
 the same                      dementia?                                                     INSIDE, Aslib Index to                  effect in favour of the
  study)                                                                                       theses, Dissertation                       aromatherapy
                                                                                                 Abstract (USA),                         intervention on
                                                                                          http://clinicalstudies.info.n              measures of agitation
                                                                                          ih.gov/, National Research                  and neuropsychiatric
                                                                                          Register, ClinicalTrails.gov,               symptoms, but there
                                                                                                     LILACS,                               were several
                                                                                          http://www.forestclinicaltr                    methodological
                                                                                                     ials.com,                         difficulties with the
                                                                                            ClinicalStudyResults.org,                         study.
                                                                                          http://lillytrials.com/inde
                                                                                           x.shtml, ISRCTN Register,
                                                                                              IPFMA Clinical Trials
                                                                                            Register, Lundbeck Trial
                                                                                                Registry; journals:
                                                                                          Complementary Therapies
                                                                                                   in Medicine,
                                                                                          Complementary Therapies
                                                                                           in Nursing and Midwifery




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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                       Comments
  Year       assessme                                                                                                   aromath        Conclusions
             nt of the                                                                                                    erapy
              review                                                                                                     studies
                                                                                                                       reviewed
Robinson        ++          To determine the      Search carried     Full details of    Included Cochrane Library,          2        Overall no robust      Clear review with comprehensive
  2006 /                     clinical and cost    out up to and      search terms          MEDLINE, EMBASE,                           evidence of the         description of methodology,
2007 (two                   effectiveness and      including 31      contained in         Central CINAHL, Social                   efficacy the evidence       literature and findings. The
 papers                   acceptability of non-     March 2005         appendix           Science Citation Index,                   deemed to be of low      conclusions are in line with the
reporting                   pharmacological                                               Science Citation Index,                   quality. Two RCTs;                   findings.
   same                      interventions to                                               PsycINFO, ADEAR,                            one showed
  study)                   reduce wandering                                             National Research Register,                participants receiving
                                 dementia                                                     ETHX database,                       essential oils showed
                                                                                            Bioethicsweb, ISTP,                       less wandering
                                                                                            ZETOC,, Journal of                     behaviour (marginal
                                                                                        Dementia Care (1999-2004),                        statistical
                                                                                        Dementia (2002-4), personal                  significance); the
                                                                                         contact with specialists in                  other found no
                                                                                                  the field                              difference.

Diamond          -          To review use of        1982-2002      Numerous terms       Medline, Research Council         7         The studies among        Likely to overestimate results as
  2003                   alternative substances                     listed in paper –     for Complementary                             persons with        study quality is not assessed – all
                            to ameliorate the                      but no dementia        Medicine, PsycINFO,                        dementia indicate      appear to have been given equal
                         cognitive, psychiatric                    terms mentioned       Ingenta plc, Cochrane                      that aromatherapy                     weight
                            and behavioural                                              Database of Systematic                    may have moderately
                              symptoms of                                                        Reviews                             beneficial effects.
                                dementia                                                                                             Better controlled
                                                                                                                                    studies with larger
                                                                                                                                      sample sizes are
                                                                                                                                    needed to evaluate
                                                                                                                                        the effect of
                                                                                                                                   aromatherapy on the
                                                                                                                                   affect and behaviour
                                                                                                                                      of persons with
                                                                                                                                         dementia




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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       assessmen                                                                                                            studies
              t of the                                                                                                           reviewed
               review
Robinson         ++           To determine the       Search carried   Full details of search    Included Cochrane Library,          1          This study did not      Clear review with comprehensive
  2006 /                       clinical and cost     out up to and     terms contained in          MEDLINE, EMBASE,                          provide evidence that   description of methodology, literature
2007 (two                     effectiveness and      including 31           appendix              Central CINAHL, Social                      the intervention was    and findings. The conclusions are in
papers on                   acceptability of non-     March 2005                                   Science Citation Index,                         effective in              line with the findings.
   same                       pharmacological                                                      Science Citation Index,                    preventing/reducing
  study)                   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
Livingsto        +          A systematic review        Electronic      terms encompassing          Electronic databases;           25        25 papers report on      Overall a comprehensive review
    n                         of psychological        database up     individual dementias          reference lists from                    non-dementia specific    that is let down by lack of detail in
  2005                       approaches to the       to July 2003,     and interventions –        individual and review                         psychological        the search strategy which means it
                              management of              Hand           no further details      articles, Cochrane Library                  therapies for patients    is not replicable. In addition, due
                              neuropsychiatric         searched               given             plus hand searched three                    with dementia, nearly    to the very large number of papers
                                symptoms of          three journal                              journals (titles not given)                      all examined        included in the review (162), other
                             dementia with the         during 10                                                                                 behavioural           than highlighting the RCTs it is
                               aim of making          year period                                                                                management          difficult to determine study design
                               evidence based          up to July                                                                              techniques. The             or details such as sample
                             recommendations              2003                                                                               studies were judged           characteristics or setting.
                           about the use of these                                                                                            to be relatively high
                                interventions                                                                                                quality. The authors
                                                                                                                                                report that the
                                                                                                                                            findings of the larger
                                                                                                                                             RCT were consistent
                                                                                                                                            and positive, and the
                                                                                                                                               effects lasted for
                                                                                                                                                    months




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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       assessmen                                                                                                      studies
              t of the                                                                                                     reviewed
               review
 Verkaik         +             The effect of         Search carried    Numerous terms            Pubmed, Cochrane              1            There is limited          Overall a comprehensive review;
  2005                     psychosocial methods         out from      included and listed   CENTRAL/CCTR, Cochrane                        evidence (one high       however, there is no discussion of the
                               on depressed,           September                               Database of Systematic                      quality RCT) that         strength of evidence for no effect /
                          aggressive and apathetic      2002 to                                Reviews, PsychINFO,                       people with probable       negative effect - only positive effect
                           behaviours of people      February 2003                              EMBASE, CINAHL,                          Alzheimer‟s disease
                               with dementia                                                INVERT, NIVEL, Cochrane                       living at home with
                                                                                            Specialized Register, CDCIG,                   depression are less
                                                                                                   SIGLE, DARE.                          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.




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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        assessmen                                                                                                         studies
               t of the                                                                                                        reviewed
                review
Clare 2007        ++             To evaluate the       Search carried   Numerous, listed in   Specialised Register contained    9 (all          The available evidence remains           Comprehensive review
                           effectiveness and impact    out April 2006        paper             records from : CENTRAL,          RCTs)       limited, but there is still no indication       with clear search
                           of cognitive training and   and September                             MEDLINE, EMBASE,                               of any significant effects from            strategy, terms and
                            cognitive rehabilitation        2006                              PsycINFO, CINAHL, SIGLE,                                  cognitive training.              criteria but as noted by
                             interventions aimed at                                            ISTP, INSIDE plus Theses                             The use of standardised             the authors The use of
                            improving memory and                                                   and on-going trials                        neuropsychological measures may                  standardised
                                 other aspects of                                                                                              result in positive effects on daily         neuropsychological
                              cognitive functioning                                                                                        living capabilities going unrecognised.       measures may result in
                             for people in the early                                                                                              It is not possible at to draw         positive effects on daily
                             stages of Alzheimer‟s                                                                                             conclusions about the efficacy of        living capabilities going
                               disease or vascular                                                                                          individualised cognitive rehabilitation           unrecognised.
                                    dementia                                                                                                  interventions for people with early
                                                                                                                                             stage dementia due to lack of RCTs.
Grandmai          +             To review the          As indicated      Numerous search      Medline (1971), PsychINFO           17            The results suggest that it is              Comprehensive
son 2003                       evidence on the         by database       terms outlined in           (1887-2001)                             possible to stimulate memory in             review but inclusion
                           efficacy of stimulation                              text                                                       AD. The errorless learning, spaced           of only two databases
                                 strategies or                                 Clear                                                           retrieval, and vanishing clues             for the search may
                           programmes with the                          inclusion/exclusio                                                     techniques, together with the                 have led to the
                               AD population                                 n criteria                                                      dyadic approach seem to present            exclusion of pertinent
                                                                                                                                               the best training methods for                     studies.
                                                                                                                                              patients with AD. But there is a               As the authors
                                                                                                                                              need for more RCTs to validate              suggest, whilst the
                                                                                                                                                  this treatment approach.                evidence suggests
                                                                                                                                                                                          positive results the
                                                                                                                                                                                          majority of studies
                                                                                                                                                                                         contain small sample
                                                                                                                                                                                           numbers making
                                                                                                                                                                                            identification of
                                                                                                                                                                                        statistically significant
                                                                                                                                                                                             improvements
                                                                                                                                                                                                difficult.




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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        assessmen                                                                                                        studies
               t of the                                                                                                       reviewed
                review
Sitzer 2006       ++          To systematically       Up to 2004 as    Cognitive              Medline (1953-2004) &               19       Cognitive training evidenced         Overall a well present
                            review the literature     per details of   rehabilitation,        PsychINFO (1840-2004)                        promise in the treatment of AD,      and clear review and
                             and summarise the         databases       cognitive training,                                                 with primarily medium effect sizes   analysis. However, it
                              effect of cognitive                      cognitive                                                           for learning memory, executive       is interesting to note
                                  training for                         remediation,                                                        functioning, ADL, general            that studies identified
                            Alzheimer’s disease                        memory training,                                                    cognitive problems, depression,      as higher quality
                                                                       attention training,                                                 self-rated general functioning.      ‘painted a less
                                                                       Alzheimer’s                                                         Restorative strategies               optimistic picture of
                                                                       disease                                                             demonstrated the greatest effect     efficacy’. The studies
                                                                                                                                           on functioning. Limitations: small   come under the
                                                                                                                                           number of well controlled studies;   cognitive training
                                                                                                                                           small sample numbers and             umbrella but include a
                                                                                                                                           difficulties associated with         diverse range of
                                                                                                                                           outcome measures. Evidence of        interventions
                                                                                                                                           maintenance of gains is based on     (including reality
                                                                                                                                           only six papers.                     orientation and
                                                                                                                                                                                reminiscence therapy).




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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        Databases searched        No of cognition studies   Author’s Conclusions                     Comments
  Year        assessmen                                                 terms used                                       reviewed
               t of 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                        10 grey literature                                significant improvement     excluded on grounds of quality, the
                                psychological         April and June                      sources – details                                     in functional and      four retained had low sample size and
                           interventions for people        2002                          contained in study                                     cognitive ability.       no power calculations which could
                            with milder dementing                                             appendix                                        Therefore the review            overstate positive results
                                    illness                                                                                                      did not find any
                                                                                                                                                 evidence of the
                                                                                                                                                 effectiveness of
                                                                                                                                               procedural memory
                                                                                                                                                   stimulation.
Livingston        +         A systematic review of      Electronic          terms       Electronic databases;               4                   Mostly consistent      Overall a comprehensive review that is
   2005                          psychological        database up to   encompassin       reference lists from                                evidence that cognitive     let down by lack of detail in search
                              approaches to the         July 2003,      g individual    individual and review                                  stimulation therapy          strategy which means it is not
                               management of          Hand searched      dementias        articles, Cochrane                                   improves aspects of     replicable. In addition, due to the very
                               neuropsychiatric        three journal         and          Library plus hand                                     neuropsychiatric       large number of papers included in the
                            symptoms of dementia      during 10 year   interventions   searched three journals                               symptoms immediately       review (162), other than highlighting
                           with the aim of making      period up to     – no further       (titles not given)                                 and for some months        the RCTs it is difficult to determine
                                evidence based           July 2003     details given                                                               afterwards.         study design or details such as sample
                           recommendations about                                                                                             Three of the four RCTs            characteristics or setting.
                               the use of these                                                                                                  showed positive
                                 interventions                                                                                                    improvements




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Table 6. Counselling: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Counselling




  Author,         Overall        Research Question         Years          Search terms          Databases searched            No of        Author’s Conclusions on                 Comments
   Year        assessment of                              covered             used                                         counselling       Counselling Study
                the review                                                                                                   studies
                                                                                                                            reviewed
 Bates 2004          +           To investigate the        Search          Numerous          15 electronic databases, 10        1             Effectiveness of the        Overall although most studies
                                   effectiveness of      carried out                           grey literature sources –                     individual counselling        were excluded on grounds of
                                    psychological         between                             details contained in study                        sessions was not         quality, the four retained had low
                                  interventions for       April and                                    appendix                           demonstrated on the outcome       sample size and no power
                                 people with milder      June 2002                                                                               measures used.         calculations which could overstate
                                  dementing illness                                                                                                                                positive results




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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         Databases         No of studies             Authors’ Conclusions                              Comments
  Year        assessmen                              covere          used             searched           reviewed
               t of the                                d
                review
Livingston        +         A systematic review of   Electro         terms             Electronic            19              8 studies investigated the effects of    Overall a comprehensive review that is
   2005                          psychological          nic      encompassing          databases;                       changing the visual environment: consistent     let down by lack of detail in search
                              approaches to the      databas       individual        reference lists                       evidence from lower grade studies for           strategy which means it is not
                               management of         e up to     dementias and      from individual                      changing the environment to obscure the      replicable. In addition, due to the very
                               neuropsychiatric        July    interventions – no      and review                                            exit.                    large number of papers included in the
                            symptoms of dementia      2003,      further details         articles,                          2 studies investigated use of mirrors:     review (162), other than highlighting
                           with the aim of making     Hand           given              Cochrane                             inconclusive/inconsistent evidence         the RCTs it is difficult to determine
                                evidence based       searche                          Library plus                       3 studies investigated use of signposting:   study design or details such as sample
                           recommendations about     d three                         hand searched                           inconclusive/inconsistent evidence               characteristics or setting.
                               the use of these      journal                         three journals                               5 studies in group living:
                                 interventions       during                             (titles not                          inconclusive/inconsistent evidence
                                                     10 year                              given)                                   I study unlocked doors:
                                                      period                                                                 inconclusive/inconsistent evidence
                                                       up to
                                                       July
                                                       2003
 Cohen-           -              Considers              No     No details given       PsycLIT,               6             2 studies showed free access to an          The volume of studies included in
Mansfield                      inappropriate          dates                          MEDLINE,                               outdoor area,result in decreased            the overall review (n=83) mean
  2001                         behaviours in          given                         and a nursing                        agitation; 2 studies found a simulated       that some, but not all of the studies
                           dementia; a literature                                     subset of                         natural environment decreased agitated          are described, but all are given
                           search on the impact                                      MEDLINE                              behaviours; 2 studies report reduced           equal weight. Methodological
                                   of non-                                                                               agitation after initiation of a reduced        issues are presented within the
                             pharmacological                                                                                    stimulation environment.               discussion section, these relate to
                             interventions (to                                                                                                                          diverse measurement methods,
                           address the issues of                                                                                                                         criteria for success, screening
                           understanding of the                                                                                                                         procedures, control procedures
                            interventions, their                                                                                                                       and treatment of failures. Little or
                              effects and their                                                                                                                       no account is taken of study design
                                 feasibility)                                                                                                                                (RCT, case study etc).




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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        Databases         No of studies              Authors’ Conclusions                              Comments
  Year        assessmen                                covere         used            searched           reviewed
               t of the                                  d
                review
Spira 2006         -       To critically review the    1970-    No details given       PsycINFO              6           Overall the 23 reviewed studies collectively    Only one database searched which is
                            empirical literature on    2004                                                               provide evidence that warrants optimism             likely to have limited papers
                                 behavioural                                                                               regarding the application of behavioural                     identified.
                           interventions to reduce                                                                        principles to the management of agitation      The conclusions drawn by the author
                           agitation in older adults                                                                          among older adults with dementia.              suggest the studies collectively
                                with dementia                                                                            Although some of the results of some of the     provide evidence. Unfortunately the
                                                                                                                             studies are mixed and several studies       prevalence of single subject and case
                                                                                                                           revealed methodological shortcomings,            study designs together with the
                                                                                                                         many offered innovations that can be used         majority of studies measuring the
                                                                                                                             in future, more rigorously designed,         occurrence of target behaviours by
                                                                                                                                      intervention studies.             direct observation means this evidence
                                                                                                                                                                           is, at best weak and likely to over
                                                                                                                         Wandering and hazardous behaviour: taken                  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.




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Table 8a. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).




 Author,         Overall         Research         Years covered      Search terms             Databases searched               No of          Author’s Conclusions                         Comments
  Year         assessment        Question                                used                                                 studies
              of the review                                                                                                  reviewed
  Forbes           ++               What          Search carried   Bright light*, light         Specialised Register          5 (all     There is insufficient evidence to     A comprehensive review containing
   2007                       recommendatio       out December     box*, light visor*,       contained records from :         RCTs)        assess the value of bright light              RCTs only.
                              ns can be made          2005            dawn-dusk*,            CENTRAL, MEDLINE,                             therapy (BLT) for people with
                               regarding the                          phototherapy             EMBASE, PsycINFO,                        dementia. The available studies are
                              efficacy of light                         (MESH),              CINAHL, SIGLE, ISTP,                       of poor quality and further research
                                 therapy in                          phototherapy,            INSIDE, Aslib Index to                                 is required
                                 managing                           “phototherapy”,        theses, Dissertation Abstract
                              disturbances of                       “light therapy”,                    (USA),
                                    sleep,                         “light treatment”,     http://clinicalstudies.info.nih.
                                 behaviour,                              light*              gov/, National Research
                                mood and/or                                                Register, ClinicalTrails.gov,
                                  cognition                                                           LILACS,
                              associated with                                             http://www.forestclinicaltrials
                                 dementia?                                                               .com,
                                                                                             ClinicalStudyResults.org,
                                                                                          http://lillytrials.com/index.sht
                                                                                               ml, ISRCTN Register,
                                                                                               IPFMA Clinical Trials
                                                                                                       Register
 Skjerve           +           What does the        1980 –           Light, therapy,          MEDLINE, PsycINFO,               21          Despite 6 RCTs (one with good           Although some methods are
  2004                         literature say      September           treatment,                     Cochrane                          power) showing positive results for      provided regarding the literature
                                  about the          2003            phototherapy,                                                         some aspects the authors do not        search the process of selection,
                                  efficacy,                             dementia                                                         draw any conclusions on efficacy.       extraction and synthesis are not
                                   clinical                                                                                             The authors recommend study into                     presented.
                               practicability                                                                                              the effects on people with mild        There is no report of the initial
                               and safety of                                                                                               dementia suggesting successful       number of hits. Inclusion criteria
                              light treatment                                                                                            treatment may be more likely and        are given but not the process for
                              for behavioural                                                                                                  may reduce the need for         identifying the 21 included studies.
                                     and                                                                                                    institutionalisation. Different      Despite several RCTs (one with
                               psychological                                                                                            effects may be due to differences in      good power) showing positive
                               symptoms of                                                                                                 treatment (brightness, duration,    results for some aspects the authors
                                 dementia?                                                                                               timing) or condition (e.g. vascular     do not draw any conclusions on
                                                                                                                                             dementia) which have been                        efficacy.
                                                                                                                                                 insufficiently tested.




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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                                                                                                   studies
              of the review                                                                                                reviewed
Kim 2003            -             To evaluate the         No clear         Not reported                Not reported          14       A need clearly exists for        Limited search methodology is
                              effects of bright light                                                                                       well-designed          reported and no methodology for data
                               therapy on the sleep                                                                                     controlled studies to         extraction / selection / synthesis.
                                 and behaviour of                                                                                     look at the relationship      Database(s) not reported, nor search
                                dementia patients                                                                                         among dementia,         terms, number of initial hits or process
                                                                                                                                           agitation, sleep-         for selection. Inclusion/exclusion
                                                                                                                                      wakefulness and bright                 criteria are reported.
                                                                                                                                       light in community or               Adequate discussion of
                                                                                                                                            nursing home          methodological problems but divorced
                                                                                                                                             populations.             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.




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Table 8b. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Light Therapy




 Author,          Overall           Research          Years covered    Search terms used          Databases searched           No of      Author’s Conclusions                 Comments
  Year         assessment of        Question                                                                                   light
                the review                                                                                                    studies
                                                                                                                             reviewed
 Cohen-              -              Considers           No dates        No details given      PsycLIT, MEDLINE, and a            7         The results of the 7    The volume of studies included in
Mansfield                         inappropriate          given                                    nursing subset of                             studies are       the overall review mean that some,
  2001                            behaviours in                                                      MEDLINE                               inconclusive, some          but not all of the studies are
                                   dementia; a                                                                                             report a significant    described, but all are given equal
                                literature search                                                                                          decrease and some       weight. Methodological issues are
                                on the impact of                                                                                          report a trend. These      presented within the discussion
                                       non-                                                                                               differences may stem        section, these relate to diverse
                                pharmacological                                                                                            from differences in    measurement methods, criteria for
                                interventions (to                                                                                               design and            success, screening procedures,
                                   address the                                                                                            measurement or from      control procedures and treatment
                                     issues of                                                                                                differences in       of failures. Little or no account is
                                  understanding                                                                                                population.          taken of study design (RCT, case
                                       of the                                                                                                                                    study etc).
                                  interventions,
                                their effects and
                                 their feasibility)




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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        assessmen                                                                                                              studies
               t of the                                                                                                             reviewed
                review
 Viggo            ++            To assess the         Search carried   Trials identified from   Specialised Register contained      2 (both        Some evidence is          Clear review with comprehensive
 Hansen                    effectiveness of a range   out July 2005.      the Specialised         records from : CENTRAL,           RCTs)       available to support the   description of methodology, literature
  2006                      of massage and touch         No date          Register of the           MEDLINE, EMBASE,                            efficacy of two specific    and findings. However, the authors
                             therapies offered to       exclusion       Cochrane Dementia       PsycINFO, CINAHL, SIGLE,                        applications: the use of   may overstate the strength of evidence
                           patients with dementia                          and Cognitive        ISTP, INSIDE, Aslib Index to                      hand massage for an      on the basis of two small and separate
                                                                       Improvement Group         theses, Dissertation Abstract                    immediate and short                      studies.
                                                                          using the terms                     (USA),                                term reduction in
                                                                              massage,          http://clinicalstudies.info.nih.g               agitated behaviour, and
                                                                        reflexology, touch,         ov/, National Research                      the addition of touch to
                                                                               shiatsu           Register, ClinicalTrails.gov,                 verbal encouragement to
                                                                                                            LILACS,                            eat for the normalization
                                                                                                http://www.forestclinicaltrials.                  of nutritional intake.
                                                                                                               com,
                                                                                                   ClinicalStudyResults.org,
                                                                                                http://lillytrials.com/index.sht
                                                                                                ml, ISRCTN Register, IPFMA
                                                                                                    Clinical Trials Register,




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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       assessmen                                                                                                      studies
              t of the                                                                                                     reviewed
               review
Livingsto        +          A systematic review        Electronic     terms encompassing        Electronic databases;          3        The authors identify 3     Overall a comprehensive review
    n                         of psychological        database up    individual dementias        reference lists from                     studies in this area    that is let down by lack of detail in
  2005                       approaches to the       to July 2003,    and interventions –      individual and review                    only one of which is a     search strategy which means it is
                              management of              Hand          no further details    articles, Cochrane Library                    RCT. The authors        not replicable. In addition, due to
                              neuropsychiatric         searched              given           plus hand searched three                   report no evidence for     the very large number of papers
                                symptoms of          three journal                           journals (titles not given)                 sustained usefulness.    included in the review (162), other
                             dementia with the         during 10                                                                          However, the RCT,         than highlighting the RCTs it is
                               aim of making          year period                                                                         comparing calming       difficult to determine study design
                               evidence based          up to July                                                                       music, hand massage,            or details such as sample
                             recommendations              2003                                                                             music followed by            characteristics or setting.
                           about the use of these                                                                                       massage or music and
                                interventions                                                                                                    massage
                                                                                                                                        simultaneously for 10
                                                                                                                                          minutes each, finds
                                                                                                                                             all groups had
                                                                                                                                           reduced agitation
                                                                                                                                                relative to
                                                                                                                                          comparison group.
                                                                                                                                           Effect lasted for 1
                                                                                                                                                   hour.
 Cohen-           -              Considers             No dates        No details given      PsycLIT, MEDLINE, and a           83           Massage touch: 6      The volume of studies included in
Mansfield                      inappropriate            given                                    nursing subset of                       studies, one reported        the overall review) mean that
  2001                         behaviours in                                                        MEDLINE                              unequivocal success,     some, but not all of the studies are
                           dementia; a literature                                                                                          the others either a     described, but all are given equal
                           search on the impact                                                                                         positive trend, partial   weight. Methodological issues are
                                   of non-                                                                                               effects (physical and      presented within the discussion
                             pharmacological                                                                                            verbal behaviours) or        section, these relate to diverse
                             interventions (to                                                                                           no effect (aggression)   measurement methods, criteria for
                           address the issues of                                                                                                                     success, screening procedures,
                           understanding of the                                                                                                                   control procedures and treatment
                            interventions, their                                                                                                                   of failures. Little or no account is
                              effects and their                                                                                                                    taken of study design (RCT, case
                                 feasibility)                                                                                                                                   study etc).




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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       Author’s Conclusions            Comments
  Year        assessmen                                                                                                                               studies
               t of the                                                                                                                              reviewed
                review
Sung 2005         ++        To provide a summary        1993 - 2005       „included‟ preferred         MEDLINE, CINAHL, PsychINFO,                       8               Music listening        Clear review with
                             of the current state of                      music, individualized      PsycARTICLES, Cochrane Database of                              intervention matched        comprehensive
                             knowledge about the                             music, music,                  Systematic Reviews,                                            with personal          description of
                              effects of preferred                        agitated behaviours,                                                                     preferences has positive   methodology, literature
                               music on agitated                               dementia,                                                                               effects in reducing      and findings. The
                              behaviours for older                        Alzheimer‟s disease,                                                                        occurrence of some      conclusions are in line
                             people with dementia                         music and dementia,                                                                           forms of agitated       with the findings.
                               and to discuss the                              music and                                                                              behaviours in older
                            implications for future                       Alzheimer‟s disease                                                                       people with dementia;      Of particular strength
                             research and practice                                                                                                                       but a number of      is the concentration on
                                                                                                                                                                         methodological         the use of preferred
                                                                                                                                                                         limitations were            music only
                                                                                                                                                                    apparent in the studies
                                                                                                                                                                             reviewed
Vink 2003        ++        To assess the efficacy of       Search         Trials identified from   Specialised Register contained records from      5 (all RCTs)   Despite the five studies     Clear review with
                             music therapy in the         conducted          the Specialised           : CENTRAL, MEDLINE, EMBASE,                                   claiming a favourable       comprehensive
                                 treatment of             December           Register of the            PsycINFO, CINAHL, SIGLE, ISTP,                              effect of music therapy       description of
                             behavioural, social,       2005, updated      Cochrane Dementia       INSIDE, Aslib Index to theses, Dissertation                     in reducing problems in    methodology, literature
                           cognitive and emotional      January 2006.         and Cognitive                         Abstract (USA),                                the behavioural, social,     and findings. The
                              problems of older        No explicit date   Improvement Group        http://clinicalstudies.info.nih.gov/, National                  emotional and cognitive    conclusions are in line
                            people with dementia          exclusion       using the term music        Research Register, ClinicalTrails.gov,                          domains the review        with the findings.
                                                                                                                        LILACS,                                     does not endorse those
                                                                                                        http://www.forestclinicaltrials.com,                          claims owing to the      Of particular strength
                                                                                                              ClinicalStudyResults.org,                                poor quality of the    is the inclusion of only
                                                                                                    http://lillytrials.com/index.shtml, ISRCTN                                studies.                  RCTs
                                                                                                    Register, IPFMA Clinical Trials Register,
                                                                                                     Geronlit, Research Index, Carl Uncover,
                                                                                                                     Muscia, Omni




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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        Author’s Conclusions                        Comments
  Year        assessment of                                                                                          studies
               the review                                                                                           reviewed
 Sherratt           +          To review clinical      Assume search       Music, music       CINAHL, MEDLINE,        21       Most studies reported the           A comprehensive review that whilst
  2004                           empirical studies       conducted      therapy, dementia,    EMBASE, PsychINFO,               effects of music to be                     discussing a number of
                                   looking at the        2003. No             review             ClinPSYCH                     effective in decreasing a range      methodological issues (including,
                                effects of a variety    explicit date                                                          of challenging behaviours             for example, observational data
                                  of music on the        exclusion                                                             including aggression,                  collection methods) does not
                                   emotional and                                                                               agitation, wandering,                address study design in relation to
                                    behavioural                                                                                repetitive vocalizations and                assessment of quality
                               responses in people                                                                             irritability. Music was also
                                   with dementia                                                                               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        Music therapy,       MEDLINE, CINAHL         7       Music can be useful as an               The review question focus is
                               interventions using         present      agitated behaviour,                                    intervention to help patients            specifically concerned with
                                music to decrease      (assume 2001)     demented elderly                                      deal with agitated behaviour          reduction of agitated behaviour.
                               agitated behaviour                                                                              problems and can increase           The search strategy is not clear in as
                                 of the demented                                                                               patients‟ quality of life but the        much as inclusion criteria is
                                  elderly person                                                                               overall weakness and                 preferably with demented elderly
                                                                                                                               limitations in study design are        and no details are given of the
                                                                                                                               considerable.                         numbers of papers identified in
                                                                                                                                                                      initial screening. Limiting the
                                                                                                                               Not clear from table or text of      search to two databases may have
                                                                                                                               the number of RCTs                      reduced the papers identified




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Table 10a (cont). Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT).



  Author,         Overall        Research Question         Years          Search terms         Databases searched          No of music    Author’s Conclusions on                     Comments
   Year        assessment of                              covered             used                                           therapy       Music Therapy Study
                the review                                                                                                    studies
                                                                                                                            reviewed
Nugent 2002           -          Examine the use of        1980 –       No details given        Psychlit, CAIRSS,               19          The review supported the      The author‟s conclusions are likely
                                   music and music         present                            CINAHL, Dissertation                       premise that music and music     to overstate the effectiveness of the
                                   therapy used for       (assume                           Abstracts International plus                  therapy interventions reduce      interventions as all studies given
                                   people who have          2002)                              reviewed articles in:                     the occurrence and frequency      equal weight irrespective of study
                                ADRDs (Alzheimers                                           Journal of Music Therapy,                       of agitated behaviours for     quality. There is insufficient detail
                                 disease and related                                              Music Therapy                              those with Alzheimer‟s        or assessment of the quality of the
                                disorders) and display                                           Perspectives, The                       disease and related disorders.                  papers
                                 agitated behaviours                                        Australian Journal of Music                    Music therapy may prevent
                                                                                               Therapy, The British                        extreme forms of agitation.
                                                                                             Journal of Music Therapy                        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.




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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         Search terms         Databases searched          No of music     Author’s Conclusions on                   Comments
   Year        assessment of                              covered            used                                           therapy        Music Therapy Study
                the review                                                                                                   studies
                                                                                                                           reviewed
 Robinson           ++            To determine the         Search        Full details of   Included Cochrane Library,           1       Review found no evidence for      Clear review with comprehensive
2006, 2007                        clinical and cost      carried out      search terms        MEDLINE, EMBASE,                            the effectiveness of music        description of methodology,
(two papers                       effectiveness and       up to and       contained in       Central CINAHL, Social                         therapy; the identified          literature and findings. The
report same                     acceptability of non-   including 31        appendix          Science Citation Index,                    evidence was assessed to be       conclusions are in line with the
   study)                         pharmacological        March 2005                           Science Citation Index,                   of low quality. One RCT that                   findings.
                                   interventions to                                            PsycINFO, ADEAR,                          showed conflicting evidence
                                 reduce wandering                                          National Research Register,                   based on different measures
                                       dementia                                                   ETHX atabase,
                                                                                                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    Assume up        Full details of      Cochrane Database of            3           Music therapy has unknown       Clear review with comprehensive
                                  of treatment on         to and         search strategy     Systematic Reviews (on                              effectiveness.           description of methodology. Only
                                cognitive symptoms      including      contained on BMJ             CD-ROM)                               One RCT found that music         includes systematic reviews and
                                   of dementia?          February      Clinical Evidence        Medline [see search                         based exercise improved       RCTs. However, search terms are
                                What are the effects       2006              website                 strategy]                              cognition after 3 months         unclear. Quality assessment
                                  of treatments on                                              Embase [see search                         compared with one to one        appears to have been undertaken
                                  behavioural and                                                    strategy]                           conversation with a therapist.      within the inclusion criteria
                                   psychological                                               Other databases (e.g.                    Poor studies identified by two
                                   symptoms of                                               PsycInfo) as appropriate                    systematic reviews provided
                                     dementia?                                                Centre for Reviews and                    insufficient evidence to assess
                                                                                               Dissemination (CRD)                      the effects of music therapy in
                                                                                                      website                                people with dementia
                                                                                             Database of Abstracts of
                                                                                                Reviews of Effects
                                                                                             (DARE) online database
                                                                                                Health Technology
                                                                                            Assessment (HTA) online
                                                                                                     database
                                                                                               National Institute for
                                                                                                Health and Clinical
                                                                                           Excellence (NICE) website
                                                                                               TRIP online database




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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          Search terms         Databases searched          No of music    Author’s Conclusions on                      Comments
   Year        assessment of                                covered             used                                           therapy       Music Therapy Study
                the review                                                                                                      studies
                                                                                                                              reviewed
 Livingston          +           A systematic review        Electronic          terms             Electronic databases;           24       Consistent evidence suggests       Overall a comprehensive review
    2005                            of psychological       database up      encompassing           reference lists from                        music therapy decreases       that is let down by lack of detail in
                                   approaches to the      to July 2003,       individual         individual and review                     agitation during sessions and      search strategy which means it is
                                    management of              Hand         dementias and      articles, Cochrane Library                    immediately after. There is      not replicable. In addition, due to
                                    neuropsychiatric         searched     interventions – no    plus hand searched three                      however no evidence that         the very large number of papers
                                      symptoms of         three journal     further details    journals (titles not given)                   music therapy is useful for     included in the review (162), other
                                  dementia with the         during 10           given                                                      treatment of neuropsychiatric       than highlighting the RCTs it is
                                     aim of making         year period                                                                     symptoms in the longer term.      difficult to determine study design
                                     evidence based         up to July                                                                         Six RCTs ; all showed               or details such as sample
                                   recommendations             2003                                                                         improvements in disruptive             characteristics or setting.
                                about the use of these                                                                                                behaviour
                                      interventions
  Watson             +           Is there evidence for     Up to          feeding, eating,      CINAHL, Medline,                 13         The studies are characterised    The quality assessment criteria is
   2006                               any effective       December           dementia,         EMBASE and Cochrane                         by small sample sizes, there is   not clear. The results section
                                interventions to assist     2003             mealtimes                                                      a lack of RCTs and this type     provides a description of the
                                   older people with                                                                                       of intervention is fraught with   studies but, more critical
                                   dementia to feed?                                                                                        the problem of confounding       assessment is provided in the
                                                                                                                                                      variables.             discussion section specifically
                                                                                                                                                                             related to music therapy and
                                                                                                                                                                             assessment of feeding difficulty.
                                                                                                                                                                             The search terms are likely to have
                                                                                                                                                                             limited identification of relevant
                                                                                                                                                                             studies.




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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         Search terms          Databases searched        No of music      Author’s Conclusions on                     Comments
   Year        assessment of                             covered            used                                          therapy         Music Therapy Study
                the review                                                                                                 studies
                                                                                                                         reviewed
  Cohen-             -                Considers         No dates      No details given     PsycLIT, MEDLINE, and             11         11 studies were identified, all   The volume of studies included
 Mansfield                          inappropriate        given                                a nursing subset of                          but one reported either           in the overall review (n=83)
   2001                             behaviours in                                                 MEDLINE                                  significant reduction or         mean that some, but not all of
                                     dementia; a                                                                                            positive trend in some        the studies are described, but all
                               literature search on                                                                                    inappropriate behaviours. One           are given equal weight.
                                                                                                                                              reported no effect
                                the impact of non-                                                                                                                            Methodological issues are
                                  pharmacological                                                                                                                         presented within the discussion
                                  interventions (to                                                                                                                         section, these relate to diverse
                                address the issues                                                                                                                         measurement methods, criteria
                               of understanding of                                                                                                                               for success, screening
                                 the interventions,                                                                                                                        procedures, control procedures
                                  their effects and                                                                                                                        and treatment of failures. Little
                                   their feasibility)                                                                                                                      or no account is taken of study
                                                                                                                                                                             design (RCT, case study etc).




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Table 11a. Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).




 Author,          Overall       Research        Years          Search terms used              Databases        No of              Author’s Conclusions                       Comments
  Year        assessment of     Question       covered                                        searched        studie
                the review                                                                                       s
                                                                                                              review
                                                                                                                ed
Eggermont          ++          To evaluate     1974 -       Physical activity, exercise,    Pubmed, Web of      27        Taking the methodological quality of      A comprehensive review with
   2006                        the effect of    2005         physical therapy, fitness         Science,                    the studies and differences between       well described methodology
                                 planned                       training, behavioural          PsycINFO,                    interventions into consideration, we      using established criteria to
                                 physical                      problems, disruptive         Biomed Central                  conclude that sustained walking in            assess quality. The
                                  activity                behaviour, mood, depression,                                        particular may benefit affective      conclusions appear consistent
                               programme                  anxiety, aggression, agitation,                                           behaviour (mood).                  with the findings based
                                s on mood                    grief, happiness, apathy,                                    Taken together (the studies) physical      primarily on evidence from
                                sleep and                      emotional problems,                                         activity appears to have a beneficial                RCTs.
                                functional                 personality, quality of life,                                      impact on the quality of sleep.
                                activity in                      sleep, restlessness,                                     Taken together (the studies) physical                   .
                               people with                 wandering, general health,                                     activity may have positive effects on
                                 dementia                    functional ability, ADL,                                   functional ability in care home residents
                                                              dementia, demented,                                         but only when a long lasting exercise
                                                          Alzheimer’s disease, nursing                                            programme is applied.
                                                            home residents, cognitive                                     Affective behaviour (mood) – 5 RCTs
                                                             impairment, cognitively                                        showed inconsistent findings. Two
                                                            impaired, mild cognitive                                         showed positive effects. Of those
                                                                     impairment                                         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




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Table 11a (cont) . Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).


 Author,          Overall       Research        Years           Search terms used              Databases        No of             Author’s Conclusions                        Comments
  Year        assessment of     Question       covered                                         searched        studie
                the review                                                                                        s
                                                                                                               review
                                                                                                                 ed
 Penrose            -          To appraise      Up to        Aged, aging, older adults,         MEDLINE,       Unclea      Lack of strong evidence of statistical    A weak systematic review.
  2005                           published     Decembe     elderly, geriatric, Alzheimer’s   PREMEDLINE,          r              significance to prescribe          Many of the studies reported
                                 literature     r 2004     disease, dementia, demented,       PsycINFO, ISI               exercise/physical activity to maintain      do not reflect the review
                                on the role                  exercise, physical activity,    Web of Science,             cognitive function or prevent cognitive    question (and do not include
                               of exercise,                     resistance training,            CINAHL,                        decline in persons with AD.            participants with AD). It
                                 including                  endurance training, aerobic        AMED, ALL                                                                would appear that the
                               aerobic and                   exercise, mental, cognitive      EMB Reviews                                                           inclusion/exclusion criterion
                                 resistance                   impairment, congnition,        (Cochrane DSR,                                                             were not sufficiently
                               training , in                     cognitive function            ACP Journal                                                                    focussed.
                               maintaining                                                     Club, DARE,
                                      or                                                          CCTR,                                                                It is unclear how many
                                improving                                                     SPORTDiscus,                                                             studies are included or
                                     the                                                     OTseeker, PEDro                                                        whether primarily those with
                                 cognitive                                                                                                                              positive results were
                               function of                                                                                                                          reported; if this latter point is
                                  persons                                                                                                                            true then this may bias the
                                    with                                                                                                                                  review in favour of
                               Alzheimer’s                                                                                                                                    intervention.
                                   disease
                                                                                                                                                                    The two RCTs reported both
                                                                                                                                                                    have small sample numbers.
                                                                                                                                                                    It is not clear whether more
                                                                                                                                                                        RCTs were identified.




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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         Years covered    Search terms used        Databases searched           No of       Author’s Conclusions                Comments
   Year         assessment        Question                                                                               exercise
                   of the                                                                                                studies
                  review                                                                                                reviewed
  Robinson          ++        To determine the     Search carried     Full details of    Included Cochrane Library,         1       The study produced some             Clear review with
2006 / 2007                    clinical and cost   out up to and      search terms           MEDLINE, EMBASE,                        evidence that moderate      comprehensive description of
(two papers                   effectiveness and     including 31      contained in         Central CINAHL, Social                     intensity exercise may      methodology, literature and
  on same                      acceptability of      March 2005         appendix           Science Citation Index,                   reduce wandering. One       findings. The conclusions are
   study)                            non-                                                  Science Citation Index,                       RCT that showed            in line with the findings.
                              pharmacological                                                PsycINFO, ADEAR,                        significant reduction in
                               interventions to                                          National Research Register,                        wandering
                                    reduce                                                      ETHX atabase,
                                  wandering                                                   Bioethicsweb, ISTP,
                                   dementia                                                   ZETOC,, Journal of
                                                                                         Dementia Care (1999-2004),
                                                                                         Dementia (2002-4), personal
                                                                                          contact with specialists in
                                                                                                    the field
 Livingston          +            A systematic       Electronic           Terms              Electronic databases;         4            Graded the level of         Overall a comprehensive
    2005                           review of        database up       encompassing            reference lists from                    evidence as troublingly      review that is let down by
                                 psychological     to July 2003,        individual          individual and review                         inconsistent or            lack of detail in search
                                 approaches to         Hand           dementias and       articles, Cochrane Library                inconclusive. Two RCTs (a    strategy which means it is not
                               the management        searched       interventions – no    plus hand searched three                   walk-talk programme and     replicable. In addition, due to
                                       of          three journal      further details     journals (titles not given)                a psychomotor activation       the very large number of
                               neuropsychiatric      during 10            given                                                        programme) found no       papers included in the review
                                 symptoms of        year period                                                                         behavioural effects      (162), other than highlighting
                                dementia with        up to July                                                                                                     the RCTs it is difficult to
                                   the aim of           2003                                                                                                       determine study design or
                               making evidence                                                                                                                       details such as sample
                                     based                                                                                                                          characteristics or setting.
                               recommendation
                                s about the use
                                    of these
                                 interventions




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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          Years covered   Search terms used       Databases searched          No of        Author’s Conclusions                  Comments
   Year         assessment         Question                                                                             exercise
                   of the                                                                                               studies
                  review                                                                                               reviewed
  Cohen-              -            Considers           No dates       No details given    PsycLIT, MEDLINE, and a          4        Outdoor walks (2 studies) ;        The volume of studies
 Mansfield                       inappropriate          given                                 nursing subset of                           both found this              included in the overall
   2001                          behaviours in                                                   MEDLINE                                intervention led to        review) mean that some, but
                                  dementia; a                                                                                       decreases in inappropriate        not all of the studies are
                               literature search                                                                                            behaviour               described, but all are given
                               on the impact of                                                                                                                   equal weight. Methodological
                                      non-                                                                                              Physical activities (2      issues are presented within
                               pharmacological                                                                                       studies); author makes no     the discussion section, these
                               interventions (to                                                                                     comment in these studies     relate to diverse measurement
                                  address the                                                                                         but the table shows one      methods, criteria for success,
                                    issues of                                                                                        study reported decreased     screening procedures, control
                                 understanding                                                                                             agitation during        procedures and treatment of
                                      of the                                                                                            sensorimotor vs. the      failures. Little or no account is
                                 interventions,                                                                                     traditional programme, the     taken of study design (RCT,
                               their effects and                                                                                         other reported non                case study etc).
                                their feasibility)                                                                                       significant trend of
                                                                                                                                        decrease in agitation




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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        Databases searched         No of           Author’s Conclusions                           Comments
 Year      assessmen                                                      used                                      studies
            t of the                                                                                               reviewed
             review
Livingst       +          A systematic review of      Electronic           terms          Electronic databases;      11          Inconclusive evidence. 2 RCTs,       Overall a comprehensive review that is
   on                          psychological        database up to     encompassing        reference lists from                 one showed no immediate benefit         let down by lack of detail in search
 2005                       approaches to the         July 2003,         individual       individual and review                     compared with active ward              strategy which means it is not
                              management of         Hand searched     dementias and         articles, Cochrane                   orientation; the other showed a      replicable. In addition, due to the very
                             neuropsychiatric        three journal    interventions –       Library plus hand                  non-significant improvement when       large number of papers included in the
                          symptoms of dementia      during 10 year   no further details       searched three                   reminiscence therapy was preceded       review (162), other than highlighting
                         with the aim of making      period up to          given            journals (titles not                by reality orientation but not vice     the RCTs it is difficult to determine
                              evidence based           July 2003                                   given)                                      versa                  study design or details such as sample
                         recommendations about                                                                                                                                characteristics or setting.
                              the use of these
                               interventions
 Bates         +            To investigate the      Search carried      Numerous               15 electronic          2          Taking the two studies together       Overall although most studies were
 2004                        effectiveness of        out between                           databases, 10 grey                      there is evidence that reality      excluded on grounds of quality, the
                               psychological        April and June                         literature sources –                      orientation is an effective      four retained had low sample size and
                         interventions for people        2002                              details contained in                      intervention in improving          no power calculations which could
                          with milder dementing                                               study appendix                      cognitive ability. Neither study           overstate positive results
                                   illness                                                                                            demonstrated that reality
                                                                                                                                     orientation is effective in
                                                                                                                                      improving well-being or
                                                                                                                                    improving communication,
                                                                                                                                   functional performance and
                                                                                                                                          cognitive ability.
Verkaik        +             The effect of          Search carried   Numerous terms        Pubmed, Cochrane           5          The quality of the five studies         Overall a comprehensive review;
 2005                    psychosocial methods          out from       included and         CENTRAL/CCTR,                         was assessed to be low. Only         however, there is no discussion of the
                             on depressed,            September           listed           Cochrane Database                      one study found significant           strength of evidence for no effect /
                        aggressive and apathetic       2002 to                               of Systematic                      improvement in depression; a           negative effect - only positive effect
                         behaviours of people       February 2003                              Reviews,                               further study reported
                             with dementia                                                    PsychINFO,
                                                                                                                                improvement in apathy. There
                                                                                          EMBASE, CINAHL,
                                                                                                                                       are no or insufficient
                                                                                           INVERT, NIVEL,
                                                                                          Cochrane Specialized                          indications that the
                                                                                           Register, CDCIG,                            intervention reduces
                                                                                            SIGLE, DARE.                           depressive, aggressive or
                                                                                                                                apathetic behaviours in people
                                                                                                                                          with dementia.




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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                Databases searched                 No of            Author’s Conclusions                   Comments
  Year       assessmen                                                terms used                                                studies
              t of the                                                                                                         reviewed
               review
 Warner          ++        What are the effects on      Up to and      Full details     Cochrane Database of Systematic           1         One systematic review (containing 4      Clear review with
  2006                     cognitive symptoms of        including       of search            Reviews (on CD-ROM)                               RCTs) found that reminiscence          comprehensive
                                 dementia?            February 2006     strategy          Medline [see search strategy]                     therapy improved cognition but had         description of
                            What are the effects of                   contained on        Embase [see search strategy]                       no effect on behavioural measures.     methodology. Only
                               treatments on                          BMJ Clinical      Other databases (e.g. PsycInfo) as                    The included studies used diverse     includes systematic
                              behavioural and                           Evidence                    appropriate                            measures and were often small. Larger    reviews and RCTs.
                               psychological                             website      Centre for Reviews and Dissemination                   and better studies on reminiscence    However, search terms
                           symptoms of dementia?                                                  (CRD) website                                      therapy are needed             are unclear. Quality
                                                                                       Database of Abstracts of Reviews of                                                         assessment appears to
                                                                                        Effects (DARE) online database                                                             have been undertaken
                                                                                         Health Technology Assessment                                                               within the inclusion
                                                                                              (HTA) online database                                                                       criteria
                                                                                        National Institute for Health and
                                                                                       Clinical Excellence (NICE) website
                                                                                               TRIP online database

  Woods          ++         Assess the effects of       Up to and     reminiscence    Specialised Register contained records    5 (data    The meta-analysis results were            A clear and concise
  2005                     reminiscence therapy       including May                   from : CENTRAL, MEDLINE,                 extracted   statistically significant for                 review. The
                           for older people with           2004                       EMBASE, PsycINFO, CINAHL,                 from 4)    cognition (at follow-up), mood (at      conclusions drawn are
                            dementia and their                                        SIGLE, ISTP, INSIDE, plus Theses                     follow-up), and on a measure of             hampered by the
                                 caregivers                                           and on-going trials. Full details                    general behavioural function (at           small number and
                                                                                      included in paper
                                                                                                                                           end of intervention period).             relatively low quality
                                                                                                                                           Improvement in cognition was                   of RCTs, as
                                                                                                                                           evident in comparison with both            highlighted by the
                                                                                                                                           no treatment and social contact                 authors.
                                                                                                                                           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.




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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            Databases searched                 No of    Author’s Conclusions                      Comments
  Year       assessmen                                                      used                                                  studies
              t of the                                                                                                           reviewed
               review
Livingston       +          A systematic review of      Electronic          terms        Electronic databases; reference lists      5            Assigned a grade       Overall a comprehensive review that is
   2005                          psychological        database up to    encompassing     from individual and review articles,               equivalent to troublingly     let down by lack of detail in search
                              approaches to the         July 2003,        individual         Cochrane Library plus hand                           inconsistent or            strategy which means it is not
                               management of          Hand searched    dementias and       searched three journals (titles not              inconclusive studies. Of    replicable. In addition, due to the very
                               neuropsychiatric        three journal   interventions –                  given)                              the three RCTs included     large number of papers included in the
                            symptoms of dementia      during 10 year      no further                                                             one found a non-        review (162), other than highlighting
                           with the aim of making      period up to      details given                                                      significant improvement       the RCTs it is difficult to determine
                                evidence based           July 2003                                                                              when reminiscence       study design or details such as sample
                           recommendations about                                                                                              therapy was preceded              characteristics or setting.
                               the use of these                                                                                               by reality orientation
                                 interventions                                                                                               but not vice versa; the
                                                                                                                                             other found no benefit
 Verkaik          +             The effect of         Search carried   Numerous terms           Pubmed, Cochrane                    2        One RCTof low quality         Overall a comprehensive review;
  2005                      psychosocial methods         out from       included and       CENTRAL/CCTR, Cochrane                              reports significantly    however, there is no discussion of the
                                on depressed,           September           listed       Database of Systematic Reviews,                        lower self-reported       strength of evidence for no effect /
                           aggressive and apathetic      2002 to                         PsychINFO, EMBASE, CINAHL,                          depression at post-test     negative effect - only positive effect
                            behaviours of people      February 2003                        INVERT, NIVEL, Cochrane                             (but was higher than
                                with dementia                                              Specialized Register, CDCIG,                        control at baseline).
                                                                                                  SIGLE, DARE.




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Table 14a. Snoezelen Therapy/Multisensory Stimulation: Key Characteristics of included systematic reviews (including at least one RCT).




 Author,         Overall      Research Question        Years covered        Search             Databases searched              No of studies       Author’s Conclusions                     Comments
  Year         assessment                                                 terms used                                            reviewed
              of the review
  Chung            ++          What is the efficacy    Original review        Trials      Specialised Register contained          3 papers         Overall no evidence for         A comprehensive update of a
  2002                          of snoezelen as a           2002;          identified       records from : CENTRAL,             representing      efficacy of snoezelen for             previous review.
                                   therapeutic           subsequent         from the           MEDLINE, EMBASE,                two trials (all    dementia. There is a need
                              intervention for older    update 2004.      Specialised     PsycINFO, CINAHL, SIGLE,                 RCTs)            for more reliable and
                                   people with             No date        Register of     ISTP, INSIDE, Aslib Index to                              sound research-based
                                    dementia?             exclusion      the Cochrane      theses, Dissertation Abstract                           evidence to inform and
                                                                           Dementia                      (USA),                                  justify the use of snoezelen
                                                                               and       http://clinicalstudies.info.nih.gov                           in dementia care.
                                                                           Cognitive      /, National Research Register,
                                                                         Improvement       ClinicalTrails.gov, LILACS,
                                                                          Group using    http://www.forestclinicaltrials.co
                                                                            the terms      m, ClinicalStudyResults.org,
                                                                           snoezelen,    http://lillytrials.com/index.shtml,
                                                                         multi-sensory       ISRCTN Register, IPFMA
                                                                                              Clinical Trials Register,
                                                                                         Lundbeck Clinical Trial Registry
 Lancioni           -          Examining within-         No details       No details        PSYCLIT, Medical Express           21 but only 7          Authors „tentative              Only PSYCLIT and Medical
  2002                        session, post-session       given                                                                 relating to            considerations‟:          Express databases were included in
                                and longer-term                                                                                  dementia          1. Snoezelen may have        the computerised search. No details
                              effects of snoezelen                                                                                                 positive within-session          of keywords used, numbers of
                                with people with                                                                                                 effects on stereotypes that            papers initially retrieved,
                                 developmental                                                                                                     are self-stimulatory in          inclusion/exclusion criteria, or
                                 disabilities and                                                                                                       nature and on                       process followed.
                                    dementia                                                                                                           social/emotional         There is a very limited discussion of
                                                                                                                                                 behaviours that are part of           study methodologies that is
                                                                                                                                                 a withdrawal condition in       divorced from the results and does
                                                                                                                                                      dementia patients.         not provide strong guidance on the
                                                                                                                                                  2. Such positive effects            interpretation of results from
                                                                                                                                                    could be increased by            individual studies. The poor
                                                                                                                                                    choosing appropriate          literature search and inclusion of
                                                                                                                                                    stimuli for individual        (presumably) low-quality studies
                                                                                                                                                         participants.            without significant discussion of
                                                                                                                                                    3. Increasing within-          this may result in effects being
                                                                                                                                                   session positive effects                     overstated
                                                                                                                                                 may increase post-session
                                                                                                                                                            effects.




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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       assessmen                                                                                                             snoezelen
              t of the                                                                                                               / MSS
               review                                                                                                               studies
                                                                                                                                   reviewed
Robinson         ++           To determine the       Search carried   Full details of search    Included Cochrane Library,              3      Some evidence, albeit of      Clear review with comprehensive
  2006 /                       clinical and cost     out up to and     terms contained in          MEDLINE, EMBASE,                               poor quality, for the    description of methodology, literature
2007 (two                     effectiveness and      including 31           appendix              Central CINAHL, Social                         effectiveness of multi-    and findings. The conclusions are in
papers on                   acceptability of non-     March 2005                                   Science Citation Index,                       sensory environment.              line with the findings.
   same                       pharmacological                                                      Science Citation Index,                        Three RCTs; two did
  study)                   interventions to reduce                                             PsycINFO, ADEAR, National                          not provide evidence
                            wandering dementia                                                   Research Register, ETHX                           that a multisensory
                                                                                               atabase, Bioethicsweb, ISTP,                    environment effectively
                                                                                               ZETOC,, Journal of Dementia                     prevents wandering; the
                                                                                                Care (1999-2004), Dementia                      third provide no follow
                                                                                                 (2002-4), personal contact                       up details and so the
                                                                                                 with specialists in the field                       study yielded no
                                                                                                                                                    information about
                                                                                                                                                       effectiveness.

Livingston        +         A systematic review of     Electronic     terms encompassing            Electronic databases;             6           Consistent evidence      Overall a comprehensive review that is
   2005                          psychological       database up to   individual dementias     reference lists from individual                    from non-RCTs; the         let down by lack of detail in search
                              approaches to the        July 2003,      and interventions –      and review articles, Cochrane                   effects are apparent for        strategy which means it is not
                               management of         Hand searched      no further details       Library plus hand searched                      only very short time      replicable. In addition, due to the very
                               neuropsychiatric       three journal           given            three journals (titles not given)                after the session. Three   large number of papers included in the
                            symptoms of dementia     during 10 year                                                                            RCTs; one with no clear      review (162), other than highlighting
                           with the aim of making     period up to                                                                                 results; two found        the RCTs it is difficult to determine
                                evidence based          July 2003                                                                                 disruptive behaviour     study design or details such as sample
                           recommendations about                                                                                               briefly improved outside            characteristics or setting.
                               the use of these                                                                                                the treatment setting but
                                 interventions                                                                                                 there was no effect after
                                                                                                                                                 the treatment stopped




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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        assessmen                                                                                                      snoezelen
               t of the                                                                                                       / multi-
                review                                                                                                        sensory
                                                                                                                              studies
                                                                                                                             reviewed
 Verkaik          +             The effect of         Search carried     Numerous terms            Pubmed, Cochrane              3        There is some evidence          Overall a comprehensive review;
  2005                      psychosocial methods         out from       included and listed   CENTRAL/CCTR, Cochrane                        (from 2 high quality       however, there is no discussion of the
                                on depressed,           September                                Database of Systematic                       RCTs) that multi-          strength of evidence for no effect /
                           aggressive and apathetic      2002 to                                 Reviews, PsychINFO,                               sensory              negative effect - only positive effect
                            behaviours of people      February 2003                               EMBASE, CINAHL,                          stimulation/Snoezelen
                                with dementia                                                 INVERT, NIVEL, Cochrane                     in a multi-sensory room
                                                                                              Specialized Register, CDCIG,                    reduces apathy in
                                                                                                     SIGLE, DARE.                            people in the latter
                                                                                                                                             stages of dementia.

 Cohen-           -              Considers              No dates        No details given      PsycLIT, MEDLINE, and a            4           Most studies report        The volume of studies included in
Mansfield                      inappropriate             given                                    nursing subset of                        improvement though it         the overall review (n=83) mean
  2001                         behaviours in                                                         MEDLINE                                  is not necessarily       that some, but not all of the studies
                           dementia; a literature                                                                                          statistically significant     are described, but all are given
                           search on the impact                                                                                                                           equal weight. Methodological
                                   of non-                                                                                                                               issues are presented within the
                             pharmacological                                                                                                                            discussion section, these relate to
                             interventions (to                                                                                                                           diverse measurement methods,
                           address the issues of                                                                                                                          criteria for success, screening
                           understanding of the                                                                                                                          procedures, control procedures
                            interventions, their                                                                                                                        and treatment of failures. Little or
                              effects and their                                                                                                                        no account is taken of study design
                                 feasibility)                                                                                                                                 (RCT, case study etc).




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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        assessmen                                                                                                        exercise
               t of the                                                                                                         studies
                review                                                                                                         reviewed
 Cameron          ++          To determine the           Up to         TENS,                  Specialised Register contained     9 (of     TENS produced a                  A comprehensive and well
  2003                        effectiveness and      December 2005     ‘transcutaneous        records from : CENTRAL,           which 3    statistically significant       designed review. The review
                            safety of TENS in the                      electrical nerve       MEDLINE, EMBASE,                 included    improvement directly          suggests the potential benefits of
                           treatment of dementia                       stimulation’           PsycINFO, CINAHL, SIGLE,          in meta    after treatment in            TENS for people with dementia.
                                                                       ‘electrical            ISTP, INSIDE, plus Theses        analysis)   delayed recall in one       The studies included demonstrated
                                                                                              and on-going trials. Full
                                                                       stimulation’                                                        trial, face recognition         consistency in experimental
                                                                                              details included in paper
                                                                       ‘cranial                                                            in two trials and           designs, subjects, interventions and
                                                                       electrostimulation’                                                 motivation in one                  outcome measures but
                                                                       ‘cranial                                                            trial. No effect on the      unfortunately only three could be
                                                                       stimulation’                                                        other                           used in the meta-analysis. As
                                                                                                                                           neuropsychological               suggested by the authors to
                                                                                                                                           and behaviour                increase the generalisability of the
                                                                                                                                           measures either             findings to a wider population the
                                                                                                                                           directly after or 6             work be replicated in a larger
                                                                                                                                           weeks after                         group of individuals.
                                                                                                                                           treatment/
                                                                                                                                           Authors conclude:
                                                                                                                                           TENS may 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.




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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        assessmen                                                                                                            exercise
               t of the                                                                                                             studies
                review                                                                                                             reviewed
Neal 2003         ++        What is the efficacy of    Search carried   Validation therapy,    Specialised Register contained        3 (all       All in all there is      Clear review with comprehensive
                              validation therapy,       out August        VDT, emotion           records from : CENTRAL,            RCTs)       insufficient evidence    description of methodology, literature
                              offered in group or      2005. No date      oriented care            MEDLINE, EMBASE,                            from randomised trials     and findings. The conclusions are in
                           individual format, as an      exclusion                             PsycINFO, CINAHL, SIGLE,                       to allow any conclusion       line with the findings however, it
                           intervention for patients                                           ISTP, INSIDE, Aslib Index to                     about the efficacy of    should be noted that the authors report
                               with dementia or                                                 theses, Dissertation Abstract                   validation therapy for     a lack of clarity regarding whether
                            cognitive impairment?                                                            (USA),                           people with dementia or          participants have dementia.
                                                                                               http://clinicalstudies.info.nih.g                cognitive impairment
                                                                                                   ov/, National Research
                                                                                                Register, ClinicalTrails.gov,
                                                                                                           LILACS,
                                                                                               http://www.forestclinicaltrials.
                                                                                                              com,
                                                                                                  ClinicalStudyResults.org,
                                                                                               http://lillytrials.com/index.sht
                                                                                                    ml, ISRCTN Register




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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        assessmen                                                                                                           exercise
               t of the                                                                                                            studies
                review                                                                                                            reviewed
Livingston        +         A systematic review of      Electronic     terms encompassing          Electronic databases;              3      No conclusive evidence.     Overall a comprehensive review that is
   2005                          psychological        database up to   individual dementias   reference lists from individual                      Only one RCT            let down by lack of detail in search
                              approaches to the         July 2003,      and interventions –    and review articles, Cochrane                    comparing validation          strategy which means it is not
                               management of          Hand searched      no further details     Library plus hand searched                    therapy to usual care or   replicable. In addition, due to the very
                               neuropsychiatric        three journal           given          three journals (titles not given)                a social contact group.   large number of papers included in the
                            symptoms of dementia      during 10 year                                                                              No difference was       review (162), other than highlighting
                           with the aim of making      period up to                                                                             found in independent       the RCTs it is difficult to determine
                                evidence based           July 2003                                                                                outcome ratings,       study design or details such as sample
                           recommendations about                                                                                              nursing time needed or             characteristics or setting.
                               the use of these                                                                                                in use of psychotropic
                                 interventions                                                                                               medication and restraint
 Verkaik          +              The effect of        Search carried    Numerous terms             Pubmed, Cochrane                  4            No or insufficient        Overall a comprehensive review;
  2005                      psychosocial methods         out from      included and listed    CENTRAL/CCTR, Cochrane                                  evidence.          however, there is no discussion of the
                                 on depressed,          September                                Database of Systematic                      3 studies found no            strength of evidence for no effect /
                           aggressive and apathetic      2002 to                                 Reviews, PsychINFO,                         significant changes in       negative effect - only positive effect
                             behaviours of people     February 2003                               EMBASE, CINAHL,                            apathy, aggression or
                                with dementia                                                 INVERT, NIVEL, Cochrane                        depression. The fourth
                                                                                              Specialized Register, CDCIG,                   found a significant
                                                                                                     SIGLE, DARE.                            change in depression
                                                                                                                                             after 1 year compared
                                                                                                                                             with alternate therapy
                                                                                                                                             but not usual care
                                                                                                                                             group.




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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     Comments
  Year         assessme                                                                                                                      reviewed       Conclusions
               nt of the
                review
 Herman           ++            Evaluating the             Search          Exit*, wander* or       Specialised Register contained records        0             N/A          N/A.
  2007                        effectiveness and          conducted           elopement or         from : CENTRAL, MEDLINE, EMBASE,
                                safety of non-          May 2006. No       ambulat* or walk*         PsycINFO, CINAHL, SIGLE, ISTP,
                                                        explicit date                                  INSIDE, Aslib Index to theses,
                                   pharma
                                                          exclusion                                Dissertation Abstract (USA), LILACS,
                               interventions in                                                     http://clinicalstudies.info.nih.gov/,
                            reducing wandering                                                           National Research Register,
                            in domestic settings                                                              ClinicalTrails.gov,
                                                                                                    http://www.forestclinicaltrials.com,
                                                                                                          ClinicalStudyResults.org,
                                                                                                     http://lillytrials.com/index.shtml,
                                                                                                    ISRCTN Register, IPFMA Lundbeck
                                                                                                            Clinical Trial Register
Peng 2007         ++          What is the efficacy     Search carried          Acupunc*            Specialised Register contained records        0             N/A          N/A
                             and possible adverse       out February                              from : CENTRAL, MEDLINE, EMBASE,
                            effects of acupuncture     2007. No date                               PsycINFO, CINAHL, SIGLE, LILACS,
                              therapy for treating       exclusion                                plus conference proceedings, theses and
                              vascular dementia?                                                                on-going trials
Price 2001        ++        To review non-drug /       Search carried       Exit*, wander*,        Specialised Register contained records        0             N/A          N/A
                            non-physical barriers       out January        camouflage, bars,      from : CENTRAL, MEDLINE, EMBASE,
                             to reduce wandering            2007             stripe*, grid*,       PsycINFO, CINAHL, SIGLE, LILACS,
                                 in people with                              floor*, door*,       plus conference proceedings, theses and
                               acquired cognitive                               barrier*,                       on-going trials
                                  impairment                                  elopement,
                                                                               ambulat*




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      Matrix 2a. Aggression
 Strategy        Activities to   AAT      Aromatherapy     Behaviour      Cognitive     Counselling    Environmental    Light       Music /    Physical     Reality       Reminiscence    MSS     TENS     Validation
                 relieve                  / massage or     management     stimulation                  manipulation     therapy     music      exercise     orientation   / reminscence                    /
                 boredom /                touch                                                                                     therapy    / activity                 therapy                          validation
                 distract                                                                                                                                                                                  therapy

Organsiation

Alzheimers
Society (UK)
Alzheimer‟s
Association
(USA)
Alzheimer‟s
Australia
Alzheimer*
Europe
Review (from
section two)*
       *The website states that anxiety, fear, agitation, nervousness, anger and frustration can all lead to aggressive behaviour and refers the reader to those pages for useful tips in addition to those identified
      above (http://www.alzheimer-europe.org/index.php?lm3=6761D7E11104&sh=6C43BEDD7AAD)



      Matrix 2b. Agitation or Anxiety
 Strategy        Activities to   AAT      Aromatherapy     Behaviour      Cognitive     Counselling    Environmental    Light       Music /    Physical     Reality       Reminiscence    MSS     TENS     Validation
                 relieve                  / massage or     management     stimulation                  manipulation     therapy     music      exercise     orientation   / reminscence                    /
                 boredom /                touch                                                                                     therapy    / activity                 therapy                          validation
                 distract                                                                                                                                                                                  therapy

Organsiation

Alzheimers
Society (UK)
Alzheimer‟s
Association
(USA)
Alzheimer‟s
Australia
Alzheimer*
Europe
Review (from
section two)*




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      Matrix 2c. Depression
 Strategy         Activities to   AAT        Aromatherapy   Behaviour    Cognitive     Counselling   Environmental   Light     Music /   Physical     Reality       Reminiscence    MSS   TENS   Validation
                  relieve                    / massage or   management   stimulation                 manipulation    therapy   music     exercise     orientation   / reminscence                /
                  boredom /                  touch                                                                             therapy   / activity                 therapy                      validation
                  distract                                                                                                                                                                       therapy

Organsiation

Alzheimers
Society (UK)
Alzheimer‟s
Association
(USA)
Alzheimer‟s
Australia
Alzheimer*
Europe
Review (from
section two)*




      Matrix 2d. Hallucinations
 Strategy         Activities to   AAT        Aromatherapy   Behaviour    Cognitive     Counselling   Environmental   Light     Music /   Physical     Reality       Reminiscence    MSS   TENS   Validation
                  relieve                    / massage or   management   stimulation                 manipulation    therapy   music     exercise     orientation   / reminscence                /
                  boredom /                  touch                                                                             therapy   / activity                 therapy                      validation
                  distract                                                                                                                                                                       therapy

Organsiation

Alzheimers
Society (UK)
Alzheimer‟s
Association
(USA)
Alzheimer‟s
Australia
Alzheimer
Europe
Review (from
section two)*
       *Hallucinations not referred to specifically




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     Matrix 2e. Sleeplessness
 Strategy      Activities to   AAT   Aromatherapy   Behaviour    Cognitive     Counselling   Environmental   Light     Music /   Physical     Reality       Reminiscence   MSS   TENS   Validation
               relieve               / massage or   management   stimulation                 manipulation    therapy   music     exercise     orientation   therapy                     /
               boredom /             touch                                                                             therapy   / activity                                             validation
               distract                                                                                                                                                                 therapy

Organsiation

Alzheimers
Society (UK)
Alzheimer‟s
Association
(USA)
Alzheimer‟s
Australia
Alzheimer
Europe
Review (from
section two)


     Matrix 2f. Wandering
 Strategy      Activities to   AAT   Aromatherapy   Behaviour    Cognitive     Counselling   Environmental   Light     Music /   Physical     Reality       Reminiscence   MSS   TENS   Validation
               relieve               / massage or   management   stimulation                 manipulation    therapy   music     exercise     orientation   therapy                     /
               boredom /             touch                                                                             therapy   / activity                                             validation
               distract                                                                                                                                                                 therapy

Organsiation

Alzheimers
Society (UK)
Alzheimer‟s
Association
(USA)
Alzheimer‟s
Australia
Alzheimer
Europe
Review (from
section two)




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                       APPENDIX ONE (search strategies)

Searches run 7th November 2007

1. OVID AMED 1985 - Nov 2007:
1. exp *dementia/
2. exp delirium/
3. alzheimer$.tw.
4. creutzfeldt$.tw.
5. kluver$.tw.
6. (pick$ adj disease).tw.
7. huntingdon$.tw.
8. binswanger$.tw.
9. korsako$.tw.
10. wernicke$.tw.
11. or/1-10
12. review$.ti. or review$.ab.
13. ("review" or "review academic" or "review literature").pt.
14. 12 or 13
15. 11 and 14
16. limit 15 to yr="2001 - 2007"



2. OVID CINAHL 1982 – Nov 2007
1. exp Occupational Therapy/
2. Recreational Therapy/
3. exp *Rehabilitation/
4. exp Sensory Stimulation/
5. ((occupation$ or recreation$) adj2 (therap$ or intervention$)).tw.
6. ((art$ or music$ or danc$ or drama$ or craft$ or game$) adj2 (therap$ or
intervent$)).tw.
7. ((book$ or exercis$ or work$ or vocational$ or swim$ or light$) adj2
(therap$ or intervent$)).tw.
8. bibliotherap$.tw.
9. snoezelen$.tw.
10. ((sound$ or noise$ or acoustic$) adj2 (stimulat$ or therap$)).tw.
11. dolls.tw.

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12. or/1-11
13. exp *psychotherapy/
14. (reality$ adj2 orient$).tw.
15. (reminisc$ adj2 (therap$ or intervent$ or treat$)).tw.
16. reminisce.tw.
17. ((validation$ or cognitiv$ or behavio$) adj2 (therap$ or intervent$ or
treatment$)).tw.
18. or/13-17
19. exp *Alternative Therapies/
20. (acupunctur$ or aromatherap$ or homeopath$ or hypnosis$ or reflexolog$
or witchcraft$ or meditat$).tw.
21. ((magic$ or laugh$ or comedy$ or rejuvenat$) adj2 (therap$ or
intervent$)).tw.
22. or/19-21
23. 12 or 18 or 22
24. exp *Dementia/
25. exp delirium/
26. Wernicke's Encephalopathy/
27. systematic review.pt.
28. (systemat$ adj3 review$).ti.
29. 27 or 28
30. or/24-26
31. 23 and 29 and 30
32. limit 31 to yr="2001 - 2007"



3. OVID EMBASE 1996 – Nov 2007
1. occupational therapy/
2. bibliotherap$.tw.
3. exp recreation/
4. ((occupation$ or recreation$) adj2 (therap$ or intervention$)).tw.
5. exp kinesiotherapy/
6. vocational rehabilitation/
7. Recreational Therapy/
8. exp sensory stimulation/ or auditory stimulation/
9. exp psychotherapy/

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10. ((art$ or music$ or danc$ or drama$ or craft$ or game$) adj2 (therap$ or
intervent$)).tw.
11. ((book$ or exercis$ or work$ or vocational$ or swim$ or light$) adj2
(therap$ or intervent$)).tw.
12. (reality$ adj2 orient$).tw.
13. (reminisc$ adj2 (therap$ or intervent$ or treat$)).tw.
14. reminisce.tw.
15. ((validation$ or cognitiv$ or behavio$) adj2 (therap$ or intervent$ or
treatment$)).tw.
16. exp alternative medicine/
17. exp acupuncture/ or exp acupressure/
18. religion/
19. homeopathy/
20. hypnosis/
21. exp Manipulative Medicine/
22. exp traditional medicine/
23. ginkgo biloba/
24. (acupunctur$ or aromatherap$ or homeopath$ or hypnosis$ or reflexolog$
or witchcraft$).tw.
25. meditat$.tw.
26. ((magic$ or laugh$ or comedy$ or rejuvenat$) adj2 (therap$ or
intervent$)).tw.
27. snoezelen$.tw.
28. ((faith$ or spiritual$) adj2 (healing$ or healer$)).tw.
29. exp *Dementia/
30. exp *Delirium/
31. exp *Prion Disease/
32. *korsakoff psychosis/ or *wernicke encephalopathy/ or *wernicke
korsakoff syndrome/
33. or/29-32
34. exp review/
35. (systematic$ adj3 review$).ti.
36. 34 or 35
37. or/1-28
38. 37 and 33 and 36
39. limit 38 to yr="2001 - 2008"


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4. OVID MEDLINE 1996 – Nov 2007
1. exp psychotherapy/
2. (reality adj2 orientat$).tw.
3. reality-orient$.tw.
4. validation therapy.tw.
5. reminisce.tw.
6. reminiscence.tw.
7. (cogniti$ adj2 therap$).tw.
8. (behavio$ adj2 therap$).tw.
9. (psychosocial$ adj2 (help or therap$ or intervention$ or strateg$ or
treat$)).tw.
10. or/1-9
11. exp Occupational Therapy/
12. exp bibliotherapy/
13. exp exercise therapy/
14. exp rehabilitation, vocational/
15. exp Recreation/
16. exp Sensory Art Therapies/
17. (recreation$ adj5 therapy).mp.
18. recreation.tw.
19. multi-sensory.tw.
20. (art adj5 therapy).tw.
21. (danc$ adj5 therapy).tw.
22. (swim$ adj5 therapy).tw.
23. dolls.tw.
24. snoezelen$.tw.
25. (music$ adj5 therapy).tw.
26. game.tw.
27. games.tw.
28. gaming.tw.
29. (craft$ adj5 therapy).tw.
30. (work adj2 therapy).tw.
31. (vocational adj2 therapy).tw.
32. exp Reality Therapy/
33. or/11-32

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34. exp Complementary Therapies/
35. aromatherapy$.tw.
36. acupunctur$.tw.
37. (sensory$ adj2 integrat$).tw.
38. reflexology$.tw.
39. herbal$.tw.
40. ginkgo$.tw.
41. ginseng$.tw.
42. exp Phototherapy/
43. (light$ adj therap$).tw.
44. ((acoustic$ or noise$ or sound$) adj (therap$ or stimulat$)).tw.
45. or/34-44
46. 10 or 33 or 45
47. exp *Dementia/
48. exp *Delirium/
49. exp *wernicke encephalopathy/
50. exp *korsakoff syndrome/
51. "benign senescent".tw.
52. or/47-51
53. 46 and 52
54. "review [publication type]"/
55. (systematic$ adj3 review$).ti.
56. 54 or 55
57. 53 and 56
58. limit 57 to yr="2001 - 2007"



5. OVID PSYCHINFO 2000 – Nov 2007
1. exp Occupational Therapy/
2. exp *creative arts therapy/
3. exp *exercise/
4. exp *games/
5. exp *psychodrama/
6. exp *phototherapy/
7. exp *vocational rehabilitation/


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8. bibliotherap$.tw.
9. ((art$ or music$ or danc$ or drama$ or craft$ or game$) adj2 (therap$ or
intervent$)).tw.
10. ((book$ or exercis$ or work$ or vocational$ or swim$ or light$) adj2
(therap$ or intervent$)).tw.
11. snoezelen$.tw.
12. dolls.tw.
13. or/1-12
14. exp *psychotherapy/
15. *reminiscence/
16. (reality$ adj2 orient$).tw.
17. (reminisc$ adj2 (therap$ or intervent$ or treat$)).tw.
18. reminisce.tw.
19. ((validation$ or cognitiv$ or behavio$) adj2 (therap$ or intervent$ or
treatment$)).tw.
20. or/14-19
21. exp *alternative medicine/
22. *massage/
23. exp *hypnosis/ or exp *hypnotherapy/
24. *biofeedback training/ or *holistic health/ or hypnotherapy/ or
*meditation/ or *phototherapy/
25. *dietary supplements/ or *"medicinal herbs and plants"/ or *osteopathic
medicine/
26. exp *religious practices/
27. exp *relaxation therapy/
28. exp *witchcraft/
29. (acupunctur$ or aromatherap$ or homeopath$ or hypnosis$ or reflexolog$
or witchcraft$).tw.
30. ((magic$ or laugh$ or comedy$ or rejuvenat$) adj2 (therap$ or
intervent$)).tw.
31. meditat$.tw.
32. or/21-31
33. 13 or 20 or 32
34. exp *dementia/
35. exp *delirium/
36. exp *huntingtons disease/
37. exp *korsakoffs psychosis/ or exp *wernickes syndrome/

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38. or/34-37
39. 33 and 38
40. review$.ti. or review$.ab.
41. 39 and 40

6.    WILEY COCHRANE LIBRARY REVIEWS 2007 Issue 4:
[HM-DEMENTIA, from 2001 to 2007 in all products] and limited to published
reviews

7.     Wiley Cochrane Library Database of Abstracts of Reviews of Effects
2007 Issue 4:
[(dement* OR deliriu* OR alzheimer* OR creutzfeld* OR korsakoff*) in Title,
Abstract or Keywords, from 2001 to 2007 in all products]




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                    APPENDIX TWO (data extraction template)


Methodology checklist
A.1 Methodology checklist: systematic reviews and meta-
analyses
Study identification

Include author, title, reference, year of publication
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        Well covered           Not addressed
                                                 Adequately addressed   Not reported
       and clearly focused question.             Poorly addressed       Not applicable
1.2    A description of the methodology used     Well covered           Not addressed
                                                 Adequately addressed   Not reported
       is included.                              Poorly addressed       Not applicable
1.3    The literature search is sufficiently     Well covered           Not addressed
                                                 Adequately addressed   Not reported
       rigorous to identify all the relevant     Poorly addressed       Not applicable
       studies.
1.4    Study quality is assessed and taken       Well covered           Not addressed
                                                 Adequately addressed   Not reported
       into account.                             Poorly addressed       Not applicable
1.5    There are enough similarities between     Well covered           Not addressed
                                                 Adequately addressed   Not reported
       the studies selected to make              Poorly addressed       Not applicable
       combining them reasonable.
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             RCT      CCT               Cohort
       included in the review?
       (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




                                                        Leeds Institute of Health Sciences
                                                                                 July 2008

								
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