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 SECTION ONE Background Aim Methodology Literature Search Quality Appraisal Dementia Organisation SECTION TWO Review of Effectiveness Interventions Symptoms Interventions and Symptoms Overview of Papers Interventions 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 SECTION THREE Introduction Interventions Acupuncture Animal Assisted Therapy Aromatherapy and Massage Behaviour Management Cognitive Stimulation Therapy/Cognitive Training Counselling Environmental Manipulation (including lighting) Music / Music Therapy Physical Activity/Exercise Reality Orientation Reminiscence Therapy 4 12 12 15 16 16 18 19 20 20 20 21 22 23 23 23 24 27 29 31 35 35 37 39 41 47 50 51 53 57 58 61 61 62 62 63 65 70 71 72 72 76 79 83 84
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Snoezelen/Multi-sensory Stimulation TENS Validation Therapy Symptoms or Behaviour Creating a Relaxing Environment Activities Aggression Agitation or Anxiety Depression Hallucinations Sleeplessness Wandering SECTION FOUR Conclusion and Implications for Carers Implications for Future Research Implications for Service providers and Commissioners REFERENCES References (studies/papers included in review) References (report references) APPENDIX ONE (search strategies) APPENDIX TWO (data extraction template) TABLES, MATRICES, BOXES Table 1: Acupuncture Table 2: Animal Assisted Therapy Table 3: Aromatherapy Table 4: Behaviour Management Table 5: Cognitive Stimulation Therapy/Cognitive Training Table 6: Counselling Table 7: Environmental Manipulation Table 8: Light Therapy Table 9: Massage/Touch Table 10: Music /Music Therapy Table 11: Physical Activity/Exercise Table 12: Reality Orientation Table 13: Reminiscence Therapy Table 14: Snoezelen/Multi-sensory Stimulation Table 15: TENS Table 16: Validation Therapy Table 17: Systematic reviews that did not identify any studies for inclusion Matrix 1: Interventions and Symptoms Evidence Assessment Matrix 2: Interventions, Behaviour/Symptoms, Oganisation Box 1: Reasons for Exclusion from the Review Box 2: Types of Symptoms Box 3: Interventions and Symptoms 85 86 87 89 90 92 95 97 100 103 105 106 108 108 111 113 157 160 164 171 116 117 119 121 123 126 127 129 132 134 140 144 145 147 150 151 153 114 154 18 21 22
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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 nondrug 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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5 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.
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6 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, Light Therapy, Cognitive Reality
Stimulation,
Environmental
Manipulation,
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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7 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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8 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 wandering) Leeds Institute of Health Sciences July 2008 stimulation (aggression, depression,
9 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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10 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 Leeds Institute of Health Sciences July 2008
11 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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12 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 5
http://www.patient.co.uk/showdoc/23068719/ http://www.who.int/classifications/apps/icd/icd10online/
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13 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).
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15 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 lateonset 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 nondrug 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
8
http://www.publications.parliament.uk/pa/cm200708/cmselect/cmpubacc/228/228.pdf
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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16 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 Leeds Institute of Health Sciences July 2008
17 3. 4. Non-drug treatments 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. 2. Management of dementia in acute settings Management of dementia in long term care facilities/residential care
settings 3. 4. 5. 6. 7. 8. 9. Assessment of dementia Screening for dementia Prevention of dementia Guidelines for dementia Herbal remedies/vitamin supplements Generic reviews in gerontology 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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18 Box 1: Reasons for Exclusion from the Review Not systematic reviews only (not reviews) including at least one randomised controlled trial of a non-drug intervention Not English language The primary purpose of the review is not to evaluate the effectiveness or efficacy evidence of one or more non-drug treatments for dementia Guidelines Not received in time to be included Précis of a review only Withdrawn Background only 57 4 6
2 2 1 1 6
Total
Quality Appraisal
79
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 Leeds Institute of Health Sciences July 2008
19 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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20 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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21 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 Cognitive Function Communication Learning Memory Recall Ability to perform activities of daily living Functional Ability Quality of Life/Wellbeing Behavioural and psychological symptoms Aggression Agitation Anxiety Apathy 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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22 Interventions and Symptoms Matrix 1 on page 114 cross references the individual symptoms to intervention type to give a summary of evidence of effectiveness. Box 3 (below) provides a précis of the type of symptom and intervention. For example, Cognitive Stimulation Therapy or Training was used to address symptoms in all three categories whereas Animal Assisted Therapy was used only to address behavioural and psychological symptoms. Box 3: Interventions and Smptoms Cognitive Ability Ability to perform activities of daily living Cognitive Stimulation Therapy/Cognitive Training Counselling Light Therapy Music/Music Therapy Physical Activity/Exercise Reality Orientation Reminiscence Therapy Snoezelen/Multisensory Stimulation TENS Validation Therapy Cognitive Stimulation Therapy/Cognitive Training Physical Activity/Exercise Reality Orientation Snoezelen/Multisensory Stimulation
Behavioural and psychological symptoms Animal Assisted Therapy Aromatherapy Behaviour Management Cognitive Stimulation Therapy/Cognitive Training Environmental Manipulation Light Therapy Massage/Touch Music/Music Therapy Physical Activity/Exercise Reality Orientation Reminiscence Therapy Snoezelen/Multisensory Stimulation TENS Validation Therapy
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23 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 13
http://www.acupuncture.org.uk/content/AboutAcupuncture/acupuncture.html http://www.medical-acupuncture.co.uk/patients/
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24 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 15
http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1
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25 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 Leeds Institute of Health Sciences July 2008
26 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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27 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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28 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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29 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 nonrandomised control trial, did not provide evidence that the intervention was effective in preventing/reducing wandering.
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30 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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31 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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32 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 Leeds Institute of Health Sciences July 2008
33 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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34 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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35 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 Leeds Institute of Health Sciences July 2008
36 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 Leeds Institute of Health Sciences July 2008
37 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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38 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, sleepwakefulness 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 nonpharmacological 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 Leeds Institute of Health Sciences July 2008
39 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 Leeds Institute of Health Sciences July 2008
40 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 Leeds Institute of Health Sciences July 2008
41 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 20
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=90&pageNumber=1 http://www.bsmt.org/what_is_mt.htm 21 http://www.bsmt.org/what_is_mt.htm
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42 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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43 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 Leeds Institute of Health Sciences July 2008
44 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 nonpharmacological 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. Leeds Institute of Health Sciences July 2008
45 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 Leeds Institute of Health Sciences July 2008
46 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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47 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; CohenMansfield, 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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48 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 Leeds Institute of Health Sciences July 2008
49 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): sleep Whilst physical activity may have positive effects on functional ability Sustained walking may benefit mood Physical activity appears to have a beneficial impact on the quality of
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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50 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 Leeds Institute of Health Sciences July 2008
51 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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52 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 careworkers 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 Leeds Institute of Health Sciences July 2008
53 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, Leeds Institute of Health Sciences July 2008
54 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 researchbased 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 were & Lai, 2002). The review have authors’ tentative conclusions effects on
that
Snoezelen
may
positive
within-session
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 Leeds Institute of Health Sciences July 2008
55 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 Leeds Institute of Health Sciences July 2008
56 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. CohenMansfield (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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57 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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58 the short term (directly after treatment) in recall, face recognition and motivation. Whilst the reviewed trials were well constructed there was insufficient data for the meta-analysis to, as noted by the authors, draw strong conclusions or to recommend its clinical use for those with dementia. Validation Therapy Validation is a method of communicating with and helping disoriented very old people built on an empathetic attitude and a holistic view of individuals 22. The techniques of validation are simple to learn and can be performed within the course of a typical 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 23
http://www.vfvalidation.org/whatis.html
http://academic.evergreen.edu/curricular/hhd2000/Mukti's%20Notes/VALIDATION%20THERAPY.ht m
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59 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 Leeds Institute of Health Sciences July 2008
60 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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61 SECTION THREE Introduction The review in Section Two presented evidence of the effectiveness of nondrug 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 Leeds Institute of Health Sciences July 2008
62 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.medicalacupuncture.co.uk/) or The British Complementary Medicine Association (http://www.bcma.co.uk/).
24 25
www.alzheimer-europe.org/pages/print_article.php?idart=8E3C2105BDFD http://www.alzheimers.org.au/content.cfm?infopageid=4025#why 26 http://www.medical-acupuncture.co.uk/patients/
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63
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 28
http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1 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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64 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 individual32. 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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65 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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66 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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67 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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68 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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69 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 shows In coping with unusual behaviours such as agitation offer reassurance, Try stimulating sense of smell though visits to garden centres or flower
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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70 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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71 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 therapypleasant 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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72 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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73 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 63
http://www.columbia.edu/~mt12/blt.htm http://www.alzheimers.org.uk/downloads/non_pharmacological_therapies.pdf 64 http://www.alz.org/alzheimers_disease_10429.asp
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74 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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75 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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76 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 78
http://www.alzheimers.org.uk/factsheet/505 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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77 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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78 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 music91 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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79 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 Leeds Institute of Health Sciences July 2008
80 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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81 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.alzheimereurope.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107
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82 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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83 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.alzheimereurope.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107 112
http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6
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84 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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85 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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86 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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87 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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88 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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89 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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90 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
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91 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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92 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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93 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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94 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.alzheimereurope.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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95 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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96 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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97 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
159 160
http://www.alzheimers.org.au/content.cfm?infopageid=4515 http://www.alzheimers.org.au/content.cfm?infopageid=4515
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98 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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99 Try using different aromas: an oil burner infused with a few drops of
scented oil, fresh flowers or pot pourri to prevent agitation bath162 A hand massage using scented oil can be very soothing. Try a hand Help prevent agitation by adding a few drops of lavender oil to a
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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100 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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101 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 Leeds Institute of Health Sciences July 2008
102 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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103 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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104
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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105 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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106 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
175
176
http://www.alzheimers.org.au/content.cfm?infopageid=4465 http://www.alz.org/living_with_alzheimers_wandering_behaviors.asp http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271
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107 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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108 SECTION FOUR Conclusions and Implications for Carers The aim of this report is to help informal carers who want ideas about nondrug 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 Leeds Institute of Health Sciences July 2008
109 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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110 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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111 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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112 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.
Leeds Institute of Health Sciences July 2008
113 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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114
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 Function Communication Depression Emotional & Behavioural Responses Functional Ability Inappropriate behaviour Learning Memory
Acupuncture (no studies included) Animal Assisted Therapy Aromatherapy Behaviour Management Cognitive stimulation / rehabilitation / training Counselling Environment Manipulation Light Therapy Massage / Touch Music / music therapy Physical activity / exercise Reality orientation Reminiscence therapy Snoezelen / multi-sensory stimulation TENS Validation therapy
2
2 2
2
2 2 2
2 2 2
1 2 2 2 0 0 0 2 2 2 2 2 1 2 2 2 1 1 2 2 0 0 2 2 2 2 2 1 2 2 1 1 2 2 2 2 2 0 2 1 2 2 2
1
2
Leeds Institute of Health Sciences July 2008
115
Matrix 1b. Interventions and Symptoms: 0=Evidence of effectiveness; 1= No evidence of effectiveness; 2=inconclusive evidence
Mood Acupuncture Animal Assisted Therapy Aromatherapy Behaviour Management Cognitive stimulation / rehabilitation / training Counselling Environment Manipulation Light Therapy Massage / Touch Music / music therapy Physical activity / exercise Reality orientation Reminiscence therapy Snoezelen / multisensory stimulation TENS Validation therapy Neuropsychiatric Symptoms Nutrition Psychological Symptoms Quality of Life / Well-being Recall Sleep Social Behaviour Wandering
2 2 2 2 2
2 2 1
1 2 2 0 0 0 1 2 1 2 2 2 2 0 0 2 0 2 0 0
2
Leeds Institute of Health Sciences July 2008
116
Table 1. Acupuncture: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included
Author, Year
Peng 2007
Overall assessment of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 0
Author’s Conclusions on Counselling Study
Comments
What is the efficacy and possible adverse effects of acupuncture therapy for treating vascular dementia?
Search carried out February 2007. No details of date restrictions
Acupunct*
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, LILACS, ISTP, INSIDE, plus these, on-going trials
There is currently no evidence available from sufficiently high quality RCTs to allow assessment of the efficacy of acupuncture in the treatment of vascular dementia
Clear search criteria
Leeds Institute of Health Sciences July 2008
117
Table 2a . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT). Author, Year Overall assessme nt of the review + Research Question Years covered Search terms used Databases searched No of studies reviewed 11 Author’s Conclusions Comments
Filan 2006
To review studies that have investigated whether AAT has a measurable beneficial effect for people with dementia and specifically upon behavioural and psychological symptoms of dementia
1960-2005
Animal assisted therapy, pet and dementia
MEDLINE, PsychInfo, CINAHL
AAT appears to offer promise as a psychosocial intervention for people with dementia. The optimal frequencies and duration of AAT sessions, as well as the optimal format of such sessions, need systematic study. Studies considered a number of interventions including ‘pet visits’, introduction of a resident dog and introduction of aquaria. Results were reported in terms of: reducing agitation and/or aggression; promoting social behaviour; improving nutrition The authors point to several limitations in the studies reviewed; these include potential bias (participants have a prior history of positive interaction with animals), small sample sizes, unit of randomisation, duration of impact unclear
No details of how many studies were identified originally or screening criteria Some aspects of study design not clear – for example randomisation; small sample sizes, selection criteria is likely to overestimate results
Leeds Institute of Health Sciences July 2008
118
Table 2b . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT). General Review Including AAT
Author, Year
CohenMansfield 2001
Overall assessme nt of the review -
Research Question
Years covered
Search terms used
Databases searched
Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
No dates given
No details given
PsycLIT, MEDLINE, and a nursing subset of MEDLINE
No of AAT studies reviewed 83
Author’s Conclusions
Comments
Pet therapy: 3 studies, all report improvements
The volume of studies included in the overall review mean that some, but not all of the studies are described, but all are 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
119
Table 3a. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT). Author, Year Overall assessme nt of the review ++ Research Question Years covered Search terms used Databases searched No of studies reviewed 2 (all RCTs) Author’s Conclusions Comments
Thorgrims en 2003 / 2006 (two papers reporting the same study)
What is the evidence for the efficacy of aromatherapy as an intervention for people with dementia?
Search carried out April 2006
Aroma*, complementary therap*, alternative therap*, essential oil*
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), http://clinicalstudies.info.n ih.gov/, National Research Register, ClinicalTrails.gov, LILACS, http://www.forestclinicaltr ials.com, ClinicalStudyResults.org, 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
The additional analyses (of only one RCT) conducted 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.
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings.
Leeds Institute of Health Sciences July 2008
120
Table 3b. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Aromatherapy
Author, Year
Overall assessme nt of the review ++
Research Question
Years covered
Search terms used
Databases searched
Robinson 2006 / 2007 (two papers reporting same study)
To determine the clinical and cost effectiveness and acceptability of nonpharmacological interventions to reduce wandering dementia
Search carried out up to and including 31 March 2005
Full details of search terms contained in appendix
Included Cochrane Library, MEDLINE, EMBASE, Central CINAHL, Social Science Citation Index, Science Citation Index, PsycINFO, ADEAR, National Research Register, ETHX database, Bioethicsweb, ISTP, ZETOC,, Journal of Dementia Care (1999-2004), Dementia (2002-4), personal contact with specialists in the field Medline, Research Council for Complementary Medicine, PsycINFO, Ingenta plc, Cochrane Database of Systematic Reviews
No of aromath erapy studies reviewed 2
Author’s Conclusions
Comments
Overall no robust evidence of the efficacy the evidence deemed to be of low quality. Two RCTs; one showed participants receiving essential oils showed less wandering behaviour (marginal statistical significance); the other found no difference. The studies among persons with dementia indicate that aromatherapy may have moderately beneficial effects. Better controlled studies with larger sample sizes are needed to evaluate the effect of aromatherapy on the affect and behaviour of persons with dementia
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings.
Diamond 2003
-
To review use of alternative substances to ameliorate the cognitive, psychiatric and behavioural symptoms of dementia
1982-2002
Numerous terms listed in paper – but no dementia terms mentioned
7
Likely to overestimate results as study quality is not assessed – all appear to have been given equal weight
Leeds Institute of Health Sciences July 2008
121
Table 4. Behaviour Management: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Individualised Behaviour Management
Author, Year
Robinson 2006 / 2007 (two papers on same study)
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 1
Author’s Conclusions
Comments
To determine the clinical and cost effectiveness and acceptability of nonpharmacological interventions to reduce wandering dementia
Search carried out up to and including 31 March 2005
Full details of search terms contained in appendix
Livingsto n 2005
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassing individual dementias and interventions – no further details given
Included Cochrane Library, MEDLINE, EMBASE, Central CINAHL, Social Science Citation Index, Science Citation Index, PsycINFO, ADEAR, National Research Register, ETHX atabase, Bioethicsweb, ISTP, ZETOC,, Journal of Dementia Care (1999-2004), Dementia (2002-4), personal contact with specialists in the field Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
This study did not provide evidence that the intervention was effective in preventing/reducing wandering
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings.
25
25 papers report on non-dementia specific psychological therapies for patients with dementia, nearly all examined behavioural management techniques. The studies were judged to be relatively high quality. The authors report that the findings of the larger RCT were consistent and positive, and the effects lasted for months
Overall a comprehensive review that 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 (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Leeds Institute of Health Sciences July 2008
122
Table 4 (cont). Behaviour Management: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Individualised Behaviour Management
Author, Year
Verkaik 2005
Overall assessmen t of the review +
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 1
Author’s Conclusions
Comments
The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia
Search carried out from September 2002 to February 2003
Numerous terms included and listed
Pubmed, Cochrane CENTRAL/CCTR, Cochrane Database of Systematic Reviews, PsychINFO, EMBASE, CINAHL, INVERT, NIVEL, Cochrane Specialized Register, CDCIG, SIGLE, DARE.
There is limited evidence (one high quality RCT) 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 therapyproblem solving rather than given standard information from a therapist or no information/training.
Overall a comprehensive review; however, there is no discussion of the strength of evidence for no effect / negative effect - only positive effect
Leeds Institute of Health Sciences July 2008
123
Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Clare 2007
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 9 (all RCTs)
Author’s Conclusions
Comments
To evaluate 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 To review the evidence on the efficacy of stimulation strategies or programmes with the AD population
Search carried out April 2006 and September 2006
Numerous, listed in paper
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE plus Theses and on-going trials
Grandmai son 2003
+
As indicated by database
Numerous search terms outlined in text Clear inclusion/exclusio n criteria
Medline (1971), PsychINFO (1887-2001)
17
The available evidence remains limited, but there is still no indication of any significant effects from cognitive training. The use of standardised neuropsychological measures may result in positive effects on daily living capabilities going unrecognised. It is not possible at to draw conclusions about the efficacy of individualised cognitive rehabilitation interventions for people with early stage dementia due to lack of RCTs. The results suggest that it is possible to stimulate memory in AD. The errorless learning, spaced retrieval, and vanishing clues techniques, together with the dyadic approach seem to present the best training methods for patients with AD. But there is a need for more RCTs to validate this treatment approach.
Comprehensive review with clear search strategy, terms and criteria but as noted by the authors The use of standardised neuropsychological measures may result in positive effects on daily living capabilities going unrecognised. Comprehensive review but inclusion of only two databases for the search may have led to the exclusion of pertinent studies. As the authors suggest, whilst the evidence suggests positive results the majority of studies contain small sample numbers making identification of statistically significant improvements difficult.
Leeds Institute of Health Sciences July 2008
124
Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Sitzer 2006
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 19
Author’s Conclusions
Comments
To systematically review the literature and summarise the effect of cognitive training for Alzheimer’s disease
Up to 2004 as per details of databases
Cognitive rehabilitation, cognitive training, cognitive remediation, memory training, attention training, Alzheimer’s disease
Medline (1953-2004) & PsychINFO (1840-2004)
Cognitive training evidenced promise in the treatment of AD, with primarily medium effect sizes for learning memory, executive functioning, ADL, general cognitive problems, depression, self-rated general functioning. Restorative strategies demonstrated the greatest effect on functioning. Limitations: small number of well controlled studies; small sample numbers and difficulties associated with outcome measures. Evidence of maintenance of gains is based on only six papers.
Overall a well present and clear review and analysis. However, it is interesting to note that studies identified as higher quality ‘painted a less optimistic picture of efficacy’. The studies come under the cognitive training umbrella but include a diverse range of interventions (including reality orientation and reminiscence therapy).
Leeds Institute of Health Sciences July 2008
125
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, Year
Bates 2004
Overall assessmen t of the review +
Research Question
Years covered
Search terms used
Databases searched
No of cognition studies reviewed
Author’s Conclusions
Comments
To investigate the effectiveness of psychological interventions for people with milder dementing illness
Search carried out between April and June 2002
Numerous
15 electronic databases, 10 grey literature sources – details contained in study appendix
1
Livingston 2005
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassin g individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
4
The study found no significant improvement in functional and cognitive ability. Therefore the review did not find any evidence of the effectiveness of procedural memory stimulation. Mostly consistent evidence that cognitive stimulation therapy improves aspects of neuropsychiatric symptoms immediately and for some months afterwards. Three of the four RCTs showed positive improvements
Overall although most studies were excluded on grounds of quality, the four retained had low sample size and no power calculations which could overstate positive results
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Leeds Institute of Health Sciences July 2008
126
Table 6. Counselling: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Counselling
Author, Year
Overall assessment of the review +
Research Question
Years covered
Search terms used
Databases searched
Bates 2004
To investigate the effectiveness of psychological interventions for people with milder dementing illness
Search carried out between April and June 2002
Numerous
15 electronic databases, 10 grey literature sources – details contained in study appendix
No of counselling studies reviewed 1
Author’s Conclusions on Counselling Study
Comments
Effectiveness of the individual counselling sessions was not demonstrated on the outcome measures used.
Overall although most studies were excluded on grounds of quality, the four retained had low sample size and no power calculations which could overstate positive results
Leeds Institute of Health Sciences July 2008
127
Table 7. Environmental Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Environmental Interventions
Author, Year
Livingston 2005
Overall assessmen t of the review +
Research Question
Years covere d Electro nic databas e up to July 2003, Hand searche d three journal during 10 year period up to July 2003 No dates given
Search terms used
Databases searched
No of studies reviewed
Authors’ Conclusions
Comments
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
19
8 studies investigated the effects of changing the visual environment: consistent evidence from lower grade studies for changing the environment to obscure the exit. 2 studies investigated use of mirrors: inconclusive/inconsistent evidence 3 studies investigated use of signposting: inconclusive/inconsistent evidence 5 studies in group living: inconclusive/inconsistent evidence I study unlocked doors: inconclusive/inconsistent evidence
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
CohenMansfield 2001
-
Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
No details given
PsycLIT, MEDLINE, and a nursing subset of MEDLINE
6
2 studies showed free access to an outdoor area,result in decreased agitation; 2 studies found a simulated natural environment decreased agitated behaviours; 2 studies report reduced agitation after initiation of a reduced stimulation environment.
The volume of studies included in the overall review (n=83) mean that some, but not all of the studies are described, but all are given equal weight. 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
128
Table 7 (cont) . Environmental Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Environmental Interventions
Author, Year
Spira 2006
Overall assessmen t of the review -
Research Question
Years covere d 19702004
Search terms used
Databases searched
No of studies reviewed
Authors’ Conclusions
Comments
To critically review the empirical literature on behavioural interventions to reduce agitation in older adults with dementia
No details given
PsycINFO
6
Overall the 23 reviewed studies collectively provide evidence that warrants optimism regarding the application of behavioural principles to the management of agitation among older adults with dementia. Although some of the results of some of the studies are mixed and several studies revealed methodological shortcomings, many offered innovations that can be used in future, more rigorously designed, intervention studies. Wandering and hazardous behaviour: taken 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.
Only one database searched which is likely to have limited papers identified. The conclusions drawn by the author suggest the studies collectively provide evidence. 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.
Leeds Institute of Health Sciences July 2008
129
Table 8a. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year Forbes 2007
Overall assessment of the review ++
Research Question What recommendatio ns can be made regarding the efficacy of light therapy in managing disturbances of sleep, behaviour, mood and/or cognition associated with dementia?
Years covered
Search terms used Bright light*, light box*, light visor*, dawn-dusk*, phototherapy (MESH), phototherapy, “phototherapy”, “light therapy”, “light treatment”, light*
Databases searched
No of studies reviewed 5 (all RCTs)
Author’s Conclusions
Comments
Search carried out December 2005
Skjerve 2004
+
What does the literature say about the efficacy, clinical practicability and safety of light treatment for behavioural and psychological symptoms of dementia?
1980 – September 2003
Light, therapy, treatment, phototherapy, dementia
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), http://clinicalstudies.info.nih. gov/, National Research Register, ClinicalTrails.gov, LILACS, http://www.forestclinicaltrials .com, ClinicalStudyResults.org, http://lillytrials.com/index.sht ml, ISRCTN Register, IPFMA Clinical Trials Register MEDLINE, PsycINFO, Cochrane
There is insufficient evidence to assess the value of bright light therapy (BLT) for people with dementia. The available studies are of poor quality and further research is required
A comprehensive review containing RCTs only.
21
Despite 6 RCTs (one with good power) showing positive results for some aspects the authors do not draw any conclusions on efficacy. The authors recommend study into the effects on people with mild dementia suggesting successful treatment may be more likely and may reduce the need for institutionalisation. Different effects may be due to differences in treatment (brightness, duration, timing) or condition (e.g. vascular dementia) which have been insufficiently tested.
Although some methods are provided regarding the literature search the process of selection, extraction and synthesis are not presented. There is no report of the initial number of hits. Inclusion criteria are given but not the process for identifying the 21 included studies. Despite several RCTs (one with good power) showing positive results for some aspects the authors do not draw any conclusions on efficacy.
Leeds Institute of Health Sciences July 2008
130
Table 8a (cont). Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year Kim 2003
Overall assessment of the review -
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 14
Author’s Conclusions
Comments
To evaluate the effects of bright light therapy on the sleep and behaviour of dementia patients
No clear
Not reported
Not reported
A need clearly exists for well-designed controlled studies to look at the relationship among dementia, agitation, sleepwakefulness and bright light in community or nursing home populations.
Limited search methodology is reported and no methodology for data extraction / selection / synthesis. Database(s) not reported, nor search terms, number of initial hits or process for selection. Inclusion/exclusion criteria are reported. Adequate discussion of methodological problems but divorced from the selection of studies and results. The lack of reporting of the literature search and wide inclusion criteria could overestimate effects, however the authors do not draw any conclusions regarding effects.
Leeds Institute of Health Sciences July 2008
131
Table 8b. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Light Therapy
Author, Year CohenMansfield 2001
Overall assessment of the review -
Research Question Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
Years covered
Search terms used
Databases searched
No dates given
No details given
PsycLIT, MEDLINE, and a nursing subset of MEDLINE
No of light studies reviewed 7
Author’s Conclusions
Comments
The results of the 7 studies are inconclusive, some report a significant decrease and some report a trend. These differences may stem from differences in design and measurement or from differences in population.
The volume of studies included in the overall review mean that some, but not all of the studies are described, but all are 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
132
Table 9a. Massage and Touch: Key Characteristics of included systematic reviews (including at least one RCT). Author, Year Overall assessmen t of the review ++ Research Question Years covered Search terms used Databases searched No of studies reviewed 2 (both RCTs) Author’s Conclusions Comments
Viggo Hansen 2006
To assess the effectiveness of a range of massage and touch therapies offered to patients with dementia
Search carried out July 2005. No date exclusion
Trials identified from the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group using the terms massage, reflexology, touch, shiatsu
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), http://clinicalstudies.info.nih.g ov/, National Research Register, ClinicalTrails.gov, LILACS, http://www.forestclinicaltrials. com, ClinicalStudyResults.org, http://lillytrials.com/index.sht ml, ISRCTN Register, IPFMA Clinical Trials Register,
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.
Clear review with comprehensive description of methodology, literature and findings. However, the authors may overstate the strength of evidence on the basis of two small and separate studies.
Leeds Institute of Health Sciences July 2008
133
Table 9b. Massage and Touch: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Massage and Touch
Author, Year Livingsto n 2005
Overall assessmen t of the review +
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 3
Author’s Conclusions
Comments
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
CohenMansfield 2001
-
Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
No dates given
No details given
PsycLIT, MEDLINE, and a nursing subset of MEDLINE
83
The authors identify 3 studies in this area only one of which is a RCT. The authors report no evidence for sustained usefulness. However, the RCT, comparing 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 comparison group. Effect lasted for 1 hour. Massage touch: 6 studies, one reported unequivocal success, the others either a positive trend, partial effects (physical and verbal behaviours) or no effect (aggression)
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
The volume of studies included in the overall review) mean that some, but not all of the studies are described, but all are 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
134
Table10a. Music Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Sung 2005
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 8
Author’s Conclusions
Comments
To provide a summary of the current state of knowledge about the effects of preferred music on agitated behaviours for older people with dementia and to discuss the implications for future research and practice
1993 - 2005
„included‟ preferred music, individualized music, music, agitated behaviours, dementia, Alzheimer‟s disease, music and dementia, music and Alzheimer‟s disease
MEDLINE, CINAHL, PsychINFO, PsycARTICLES, Cochrane Database of Systematic Reviews,
Vink 2003
++
To assess the efficacy of music therapy in the treatment of behavioural, social, cognitive and emotional problems of older people with dementia
Search conducted December 2005, updated January 2006. No explicit date exclusion
Trials identified from the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group using the term music
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), http://clinicalstudies.info.nih.gov/, National Research Register, ClinicalTrails.gov, LILACS, http://www.forestclinicaltrials.com, ClinicalStudyResults.org, http://lillytrials.com/index.shtml, ISRCTN Register, IPFMA Clinical Trials Register, Geronlit, Research Index, Carl Uncover, Muscia, Omni
5 (all RCTs)
Music listening intervention matched with personal preferences has 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 Despite the five studies claiming a favourable effect of music therapy in reducing problems in the behavioural, social, emotional and cognitive domains the review does not endorse those claims owing to the poor quality of the studies.
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings. Of particular strength is the concentration on the use of preferred music only
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings. Of particular strength is the inclusion of only RCTs
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135
Table 10a (cont). Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year Sherratt 2004
Overall assessment of the review +
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 21
Author’s Conclusions
Comments
To review clinical empirical studies looking at the effects of a variety of music on the emotional and behavioural responses in people with dementia
Assume search conducted 2003. No explicit date exclusion
Music, music therapy, dementia, review
CINAHL, MEDLINE, EMBASE, PsychINFO, ClinPSYCH
Most studies reported the effects of music 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. Not clear from table or text of the number of RCTs Music can be useful as an intervention to help patients deal with agitated behaviour problems and can increase patients‟ quality of life but the overall weakness and limitations in study design are considerable. Not clear from table or text of the number of RCTs
A comprehensive review that whilst discussing a number of methodological issues (including, for example, observational data collection methods) does not address study design in relation to assessment of quality
Lou 2001
-
To review interventions using music to decrease agitated behaviour of the demented elderly person
1990- to present (assume 2001)
Music therapy, agitated behaviour, demented elderly
MEDLINE, CINAHL
7
The review question focus is specifically concerned with reduction of agitated behaviour. 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
Leeds Institute of Health Sciences July 2008
136
Table 10a (cont). Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Overall assessment of the review -
Research Question
Years covered 1980 – present (assume 2002)
Search terms used
Databases searched
Nugent 2002
Examine the use of music and music therapy used for people who have ADRDs (Alzheimers disease and related disorders) and display agitated behaviours
No details given
Psychlit, CAIRSS, CINAHL, Dissertation Abstracts International plus reviewed articles in: Journal of Music Therapy, Music Therapy Perspectives, The Australian Journal of Music Therapy, The British Journal of Music Therapy
No of music therapy studies reviewed 19
Author’s Conclusions on Music Therapy Study
Comments
The review supported the premise that music and music therapy interventions reduce the occurrence and frequency of agitated behaviours for those with Alzheimer‟s disease and related disorders. Music therapy may prevent extreme forms of agitation. Wandering and general restlessness reduced significantly. However, more rigorous designs that include refined measuring tools and studies that have larger sample sizes are required to gather more data.
The author‟s conclusions are likely to overstate the effectiveness of the interventions as all studies given equal weight irrespective of study quality. There is insufficient detail or assessment of the quality of the papers
Leeds Institute of Health Sciences July 2008
137
Table 10b. Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy
Author, Year
Overall assessment of the review ++
Research Question
Years covered
Search terms used
Databases searched
Robinson 2006, 2007 (two papers report same study)
To determine the clinical and cost effectiveness and acceptability of nonpharmacological interventions to reduce wandering dementia
Search carried out up to and including 31 March 2005
Full details of search terms contained in appendix
Warner 2006
++
What are the effects of treatment on cognitive symptoms of dementia? What are the effects of treatments on behavioural and psychological symptoms of dementia?
Assume up to and including February 2006
Full details of search strategy contained on BMJ Clinical Evidence website
Included Cochrane Library, MEDLINE, EMBASE, Central CINAHL, Social Science Citation Index, Science Citation Index, PsycINFO, ADEAR, National Research Register, ETHX atabase, Bioethicsweb, ISTP, ZETOC,, Journal of Dementia Care (19992004), Dementia (2002-4), personal contact with specialists in the field Cochrane Database of Systematic Reviews (on CD-ROM) Medline [see search strategy] Embase [see search strategy] Other databases (e.g. PsycInfo) as appropriate Centre for Reviews and Dissemination (CRD) website 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
No of music therapy studies reviewed 1
Author’s Conclusions on Music Therapy Study
Comments
Review found no evidence for the effectiveness of music therapy; the identified evidence was assessed to be of low quality. One RCT that showed conflicting evidence based on different measures
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings.
3
Music therapy has unknown effectiveness. One RCT found that music based exercise improved cognition after 3 months compared with one to one conversation with a therapist. Poor studies identified by two systematic reviews provided insufficient evidence to assess the effects of music therapy in people with dementia
Clear review with comprehensive description of methodology. Only includes systematic reviews and RCTs. However, search terms are unclear. Quality assessment appears to have been undertaken within the inclusion criteria
Leeds Institute of Health Sciences July 2008
138
Table 10b (cont) Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy
Author, Year
Overall assessment of the review +
Research Question
Years covered
Search terms used
Databases searched
Livingston 2005
Watson 2006
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions Is there evidence for any effective interventions to assist older people with dementia to feed?
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003 Up to December 2003
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
No of music therapy studies reviewed 24
Author’s Conclusions on Music Therapy Study
Comments
Consistent evidence suggests music therapy decreases agitation during sessions and immediately after. There is however no evidence that music therapy is useful for treatment of neuropsychiatric symptoms in the longer term. Six RCTs ; all showed improvements in disruptive behaviour The studies are characterised by small sample sizes, there is a lack of RCTs and this type of intervention is fraught with the problem of confounding variables.
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
feeding, eating, dementia, mealtimes
CINAHL, Medline, EMBASE and Cochrane
13
The quality assessment criteria is not clear. The results section provides a description of the studies but, more critical assessment is provided in the discussion section specifically related to music therapy and assessment of feeding difficulty. The search terms are likely to have limited identification of relevant studies.
Leeds Institute of Health Sciences July 2008
139
Table 10b (cont) Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy
Author, Year CohenMansfield 2001
Overall assessment of the review -
Research Question
Years covered No dates given
Search terms used No details given
Databases searched
Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
PsycLIT, MEDLINE, and a nursing subset of MEDLINE
No of music therapy studies reviewed 11
Author’s Conclusions on Music Therapy Study
Comments
11 studies were identified, all but one reported either significant reduction or positive trend in some inappropriate behaviours. One reported no effect
The volume of studies included in the overall review (n=83) mean that some, but not all of the studies are described, but all are given equal weight. 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
140
Table 11a. Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Overall assessment of the review ++
Research Question
Years covered
Search terms used
Databases searched
Eggermont 2006
To evaluate the effect of planned physical activity programme s on mood sleep and functional activity in people with dementia
1974 2005
Physical activity, exercise, physical therapy, fitness training, behavioural problems, disruptive behaviour, mood, depression, anxiety, aggression, agitation, grief, happiness, apathy, emotional problems, personality, quality of life, sleep, restlessness, wandering, general health, functional ability, ADL, dementia, demented, Alzheimer’s disease, nursing home residents, cognitive impairment, cognitively impaired, mild cognitive impairment
Pubmed, Web of Science, PsycINFO, Biomed Central
No of studie s review ed 27
Author’s Conclusions
Comments
Taking the methodological quality of the studies and differences between interventions into consideration, we conclude that sustained walking in particular may benefit affective behaviour (mood). Taken together (the studies) physical activity appears to have a beneficial impact on the quality of sleep. Taken together (the studies) physical activity may have positive effects on functional ability in care home residents but only when a long lasting exercise programme is applied. Affective behaviour (mood) – 5 RCTs showed inconsistent findings. Two showed positive effects. Of those negative findings one study had a short intervention period (5 days); the others two did not involve walking; hence suggestion that walking may be key. Sleep - 3 RCTs showed beneficial effect – conclude effective for sleep Functional ability: 1 RCT, this showed a positive effect
A comprehensive review with well described methodology using established criteria to assess quality. The conclusions appear consistent with the findings based primarily on evidence from RCTs. .
Leeds Institute of Health Sciences July 2008
141
Table 11a (cont) . Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Overall assessment of the review -
Research Question
Years covered
Search terms used
Databases searched
Penrose 2005
To appraise published literature on the role of exercise, including aerobic and resistance training , in maintaining or improving the cognitive function of persons with Alzheimer’s disease
Up to Decembe r 2004
Aged, aging, older adults, elderly, geriatric, Alzheimer’s disease, dementia, demented, exercise, physical activity, resistance training, endurance training, aerobic exercise, mental, cognitive impairment, congnition, cognitive function
MEDLINE, PREMEDLINE, PsycINFO, ISI Web of Science, CINAHL, AMED, ALL EMB Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, SPORTDiscus, OTseeker, PEDro
No of studie s review ed Unclea r
Author’s Conclusions
Comments
Lack of strong evidence of statistical significance to prescribe exercise/physical activity to maintain cognitive function or prevent cognitive decline in persons with AD.
A weak systematic review. Many of the studies reported do not reflect the review question (and do not include participants with AD). It would appear that the inclusion/exclusion criterion were not sufficiently focussed. It is unclear how many studies are included or whether primarily those with positive results were reported; if this latter point is true then this may bias the review in favour of intervention. The two RCTs reported both have small sample numbers. It is not clear whether more RCTs were identified.
Leeds Institute of Health Sciences July 2008
142
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, Year
Robinson 2006 / 2007 (two papers on same study)
Overall assessment of the review ++
Research Question
Years covered
Search terms used
Databases searched
To determine the clinical and cost effectiveness and acceptability of nonpharmacological interventions to reduce wandering dementia
Search carried out up to and including 31 March 2005
Full details of search terms contained in appendix
Livingston 2005
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendation s about the use of these interventions
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
Terms encompassing individual dementias and interventions – no further details given
Included Cochrane Library, MEDLINE, EMBASE, Central CINAHL, Social Science Citation Index, Science Citation Index, PsycINFO, ADEAR, National Research Register, ETHX atabase, Bioethicsweb, ISTP, ZETOC,, Journal of Dementia Care (1999-2004), Dementia (2002-4), personal contact with specialists in the field Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
No of exercise studies reviewed 1
Author’s Conclusions
Comments
The study produced some evidence that moderate intensity exercise may reduce wandering. One RCT that showed significant reduction in wandering
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings.
4
Graded the level of evidence as troublingly inconsistent or inconclusive. Two RCTs (a walk-talk programme and a psychomotor activation programme) found no behavioural effects
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Leeds Institute of Health Sciences July 2008
143
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, Year
CohenMansfield 2001
Overall assessment of the review -
Research Question
Years covered
Search terms used
Databases searched
Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
No dates given
No details given
PsycLIT, MEDLINE, and a nursing subset of MEDLINE
No of exercise studies reviewed 4
Author’s Conclusions
Comments
Outdoor walks (2 studies) ; both found this intervention led to decreases in inappropriate behaviour Physical activities (2 studies); author makes no comment in these studies but the table shows one study reported decreased agitation during sensorimotor vs. the traditional programme, the other reported non significant trend of decrease in agitation
The volume of studies included in the overall review) mean that some, but not all of the studies are described, but all are 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
144
Table 12. Reality Orientation Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reality Orientation
Author, Year
Livingst on 2005
Overall assessmen t of the review +
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 11
Author’s Conclusions
Comments
Bates 2004
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions To investigate the effectiveness of psychological interventions for people with milder dementing illness
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
Inconclusive evidence. 2 RCTs, one showed no immediate benefit compared with active ward orientation; the other showed a non-significant improvement when reminiscence therapy was preceded by reality orientation but not vice versa
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Search carried out between April and June 2002
Numerous
15 electronic databases, 10 grey literature sources – details contained in study appendix
2
Verkaik 2005
+
The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia
Search carried out from September 2002 to February 2003
Numerous terms included and listed
Pubmed, Cochrane CENTRAL/CCTR, Cochrane Database of Systematic Reviews, PsychINFO, EMBASE, CINAHL, INVERT, NIVEL, Cochrane Specialized Register, CDCIG, SIGLE, DARE.
5
Taking the two studies together there is evidence that reality orientation is an effective intervention in improving cognitive ability. Neither study demonstrated that reality orientation is effective in improving well-being or improving communication, functional performance and cognitive ability. The quality of the five studies was assessed to be low. Only one study found significant improvement in depression; a further study reported improvement in apathy. There are no or insufficient indications that the intervention reduces depressive, aggressive or apathetic behaviours in people with dementia.
Overall although most studies were excluded on grounds of quality, the four retained had low sample size and no power calculations which could overstate positive results
Overall a comprehensive review; however, there is no discussion of the strength of evidence for no effect / negative effect - only positive effect
Leeds Institute of Health Sciences July 2008
145
Table 13a. Reminiscence Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reminiscence Therapy
Author, Year
Warner 2006
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 1
Author’s Conclusions
Comments
What are the effects on cognitive symptoms of dementia? What are the effects of treatments on behavioural and psychological symptoms of dementia?
Up to and including February 2006
Full details of search strategy contained on BMJ Clinical Evidence website
Cochrane Database of Systematic Reviews (on CD-ROM) Medline [see search strategy] Embase [see search strategy] Other databases (e.g. PsycInfo) as appropriate Centre for Reviews and Dissemination (CRD) website 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 Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, plus Theses and on-going trials. Full details included in paper
One systematic review (containing 4 RCTs) found that reminiscence therapy improved cognition but had no effect on behavioural measures. The included studies used diverse measures and were often small. Larger and better studies on reminiscence therapy are needed
Clear review with comprehensive description of methodology. Only includes systematic reviews and RCTs. However, search terms are unclear. Quality assessment appears to have been undertaken within the inclusion criteria
Woods 2005
++
Assess the effects of reminiscence therapy for older people with dementia and their caregivers
Up to and including May 2004
reminiscence
5 (data extracted from 4)
The meta-analysis results 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 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.
A clear and concise review. The conclusions drawn are hampered by the small number and relatively low quality of RCTs, as highlighted by the authors.
Leeds Institute of Health Sciences July 2008
146
Table 13b. Reminiscence Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reminiscence Therapy
Author, Year
Livingston 2005
Overall assessmen t of the review +
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed 5
Author’s Conclusions
Comments
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
Verkaik 2005
+
Search carried out from September 2002 to February 2003
Numerous terms included and listed
Pubmed, Cochrane CENTRAL/CCTR, Cochrane Database of Systematic Reviews, PsychINFO, EMBASE, CINAHL, INVERT, NIVEL, Cochrane Specialized Register, CDCIG, SIGLE, DARE.
2
Assigned a grade equivalent to troublingly inconsistent or inconclusive studies. Of the three RCTs included one found a nonsignificant improvement when reminiscence therapy was preceded by reality orientation but not vice versa; the other found no benefit One RCTof low quality reports significantly lower self-reported depression at post-test (but was higher than control at baseline).
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Overall a comprehensive review; however, there is no discussion of the strength of evidence for no effect / negative effect - only positive effect
Leeds Institute of Health Sciences July 2008
147
Table 14a. Snoezelen Therapy/Multisensory Stimulation: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year Chung 2002
Overall assessment of the review ++
Research Question
Years covered
Search terms used Trials identified from the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group using the terms snoezelen, multi-sensory
Databases searched
No of studies reviewed 3 papers representing two trials (all RCTs)
Author’s Conclusions
Comments
What is the efficacy of snoezelen as a therapeutic intervention for older people with dementia?
Original review 2002; subsequent update 2004. No date exclusion
Lancioni 2002
-
Examining withinsession, post-session and longer-term effects of snoezelen with people with developmental disabilities and dementia
No details given
No details
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), http://clinicalstudies.info.nih.gov /, National Research Register, ClinicalTrails.gov, LILACS, http://www.forestclinicaltrials.co m, ClinicalStudyResults.org, http://lillytrials.com/index.shtml, ISRCTN Register, IPFMA Clinical Trials Register, Lundbeck Clinical Trial Registry PSYCLIT, Medical Express
Overall no evidence for efficacy of snoezelen for dementia. There is a need for more reliable and sound research-based evidence to inform and justify the use of snoezelen in dementia care.
A comprehensive update of a previous review.
21 but only 7 relating to dementia
Authors „tentative considerations‟: 1. Snoezelen may have positive within-session effects on stereotypes that are self-stimulatory in nature and on social/emotional behaviours that are part of a withdrawal condition in dementia patients. 2. Such positive effects could be increased by choosing appropriate stimuli for individual participants. 3. Increasing withinsession positive effects may increase post-session effects.
Only PSYCLIT and Medical Express databases were included in the computerised search. No details of keywords used, numbers of papers initially retrieved, inclusion/exclusion criteria, or process followed. There is a very limited discussion of study methodologies that is divorced from the results and does not provide strong guidance on the interpretation of results from individual studies. The poor literature search and inclusion of (presumably) low-quality studies without significant discussion of this may result in effects being overstated
Leeds Institute of Health Sciences July 2008
148
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, Year Overall assessmen t of the review ++ Research Question Years covered Search terms used Databases searched No of snoezelen / MSS studies reviewed 3 Author’s Conclusions Comments
Robinson 2006 / 2007 (two papers on same study)
To determine the clinical and cost effectiveness and acceptability of nonpharmacological interventions to reduce wandering dementia
Search carried out up to and including 31 March 2005
Full details of search terms contained in appendix
Included Cochrane Library, MEDLINE, EMBASE, Central CINAHL, Social Science Citation Index, Science Citation Index, PsycINFO, ADEAR, National Research Register, ETHX atabase, Bioethicsweb, ISTP, ZETOC,, Journal of Dementia Care (1999-2004), Dementia (2002-4), personal contact with specialists in the field
Some evidence, albeit of poor quality, for the effectiveness of multisensory environment. Three RCTs; two did not provide evidence that a multisensory environment effectively prevents wandering; the third provide no follow up details and so the study yielded no information about effectiveness. Consistent evidence from non-RCTs; the effects are apparent for only very short time after the session. Three RCTs; one with no clear results; two found disruptive behaviour briefly improved outside the treatment setting but there was no effect after the treatment stopped
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings.
Livingston 2005
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
6
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Leeds Institute of Health Sciences July 2008
149
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, Year
Overall assessmen t of the review
Research Question
Years covered
Search terms used
Databases searched
Verkaik 2005
+
The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia
Search carried out from September 2002 to February 2003
Numerous terms included and listed
Pubmed, Cochrane CENTRAL/CCTR, Cochrane Database of Systematic Reviews, PsychINFO, EMBASE, CINAHL, INVERT, NIVEL, Cochrane Specialized Register, CDCIG, SIGLE, DARE. PsycLIT, MEDLINE, and a nursing subset of MEDLINE
No of snoezelen / multisensory studies reviewed 3
Author’s Conclusions
Comments
There is some evidence (from 2 high quality RCTs) that multisensory stimulation/Snoezelen in a multi-sensory room reduces apathy in people in the latter stages of dementia. Most studies report improvement though it is not necessarily statistically significant
Overall a comprehensive review; however, there is no discussion of the strength of evidence for no effect / negative effect - only positive effect
CohenMansfield 2001
-
Considers inappropriate behaviours in dementia; a literature search on the impact of nonpharmacological interventions (to address the issues of understanding of the interventions, their effects and their feasibility)
No dates given
No details given
4
The volume of studies included in the overall review (n=83) mean that some, but not all of the studies are described, but all are given equal weight. 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. Little or no account is taken of study design (RCT, case study etc).
Leeds Institute of Health Sciences July 2008
150
Table 15. TENS: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Cameron 2003
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
To determine the effectiveness and safety of TENS in the treatment of dementia
Up to December 2005
TENS, ‘transcutaneous electrical nerve stimulation’ ‘electrical stimulation’ ‘cranial electrostimulation’ ‘cranial stimulation’
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, plus Theses and on-going trials. Full details included in paper
No of exercise studies reviewed 9 (of which 3 included in meta analysis)
Author’s Conclusions
Comments
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. No effect on the other neuropsychological and behaviour measures either directly after or 6 weeks after 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.
A comprehensive and well designed review. The review suggests the potential benefits of TENS for people with dementia. The studies included demonstrated consistency in experimental designs, subjects, interventions and outcome measures but unfortunately only three could be used in the meta-analysis. As suggested by the authors to increase the generalisability of the findings to a wider population the work be replicated in a larger group of individuals.
Leeds Institute of Health Sciences July 2008
151
Table 16a. Validation Therapy: Key Characteristics of included systematic reviews (including at least one RCT).
Author, Year
Neal 2003
Overall assessmen t of the review ++
Research Question
Years covered
Search terms used
Databases searched
What is the efficacy of validation therapy, offered in group or individual format, as an intervention for patients with dementia or cognitive impairment?
Search carried out August 2005. No date exclusion
Validation therapy, VDT, emotion oriented care
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), http://clinicalstudies.info.nih.g ov/, National Research Register, ClinicalTrails.gov, LILACS, http://www.forestclinicaltrials. com, ClinicalStudyResults.org, http://lillytrials.com/index.sht ml, ISRCTN Register
No of exercise studies reviewed 3 (all RCTs)
Author’s Conclusions
Comments
All in all there is insufficient evidence from randomised trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in line with the findings however, it should be noted that the authors report a lack of clarity regarding whether participants have dementia.
Leeds Institute of Health Sciences July 2008
152
Table 16b. Validation Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Validation Therapy
Author, Year
Livingston 2005
Overall assessmen t of the review +
Research Question
Years covered
Search terms used
Databases searched
Verkaik 2005
+
A systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia with the aim of making evidence based recommendations about the use of these interventions The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia
Electronic database up to July 2003, Hand searched three journal during 10 year period up to July 2003
terms encompassing individual dementias and interventions – no further details given
Electronic databases; reference lists from individual and review articles, Cochrane Library plus hand searched three journals (titles not given)
No of exercise studies reviewed 3
Author’s Conclusions
Comments
Search carried out from September 2002 to February 2003
Numerous terms included and listed
Pubmed, Cochrane CENTRAL/CCTR, Cochrane Database of Systematic Reviews, PsychINFO, EMBASE, CINAHL, INVERT, NIVEL, Cochrane Specialized Register, CDCIG, SIGLE, DARE.
4
No conclusive evidence. Only one RCT comparing validation therapy to usual care or a social contact group. No difference was found in independent outcome ratings, nursing time needed or in use of psychotropic medication and restraint No or insufficient evidence. 3 studies found no significant changes in apathy, aggression or depression. The fourth found a significant change in depression after 1 year compared with alternate therapy but not usual care group.
Overall a comprehensive review that is let down by lack of detail in search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (162), other than highlighting the RCTs it is difficult to determine study design or details such as sample characteristics or setting.
Overall a comprehensive review; however, there is no discussion of the strength of evidence for no effect / negative effect - only positive effect
Leeds Institute of Health Sciences July 2008
153
Table 17. Characteristics of included systematic reviews that did not identify any studies for inclusion
Author, Year
Herman 2007
Overall assessme nt of the review ++
Research Question
Years covered
Search terms used
Databases searched
No of studies reviewed
Author’s Conclusions
Comments
Evaluating the effectiveness and safety of nonpharma interventions in reducing wandering in domestic settings
Search conducted May 2006. No explicit date exclusion
Exit*, wander* or elopement or ambulat* or walk*
Peng 2007
++
Price 2001
++
What is the efficacy and possible adverse effects of acupuncture therapy for treating vascular dementia? To review non-drug / non-physical barriers to reduce wandering in people with acquired cognitive impairment
Search carried out February 2007. No date exclusion Search carried out January 2007
Acupunc*
Exit*, wander*, camouflage, bars, stripe*, grid*, floor*, door*, barrier*, elopement, ambulat*
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, Aslib Index to theses, Dissertation Abstract (USA), LILACS, http://clinicalstudies.info.nih.gov/, National Research Register, ClinicalTrails.gov, http://www.forestclinicaltrials.com, ClinicalStudyResults.org, http://lillytrials.com/index.shtml, ISRCTN Register, IPFMA Lundbeck Clinical Trial Register Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, LILACS, plus conference proceedings, theses and on-going trials Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, LILACS, plus conference proceedings, theses and on-going trials
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154
Matrix 2a. Aggression
Strategy Activities to relieve boredom / distract AAT Aromatherapy / massage or touch Behaviour management Cognitive stimulation Counselling Environmental manipulation Light therapy Music / music therapy Physical exercise / activity Reality orientation Reminiscence / reminscence therapy MSS TENS Validation / validation 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 relieve boredom / distract AAT Aromatherapy / massage or touch Behaviour management Cognitive stimulation Counselling Environmental manipulation Light therapy Music / music therapy Physical exercise / activity Reality orientation Reminiscence / reminscence therapy MSS TENS Validation / validation therapy
Organsiation Alzheimers Society (UK) Alzheimer‟s Association (USA) Alzheimer‟s Australia Alzheimer* Europe Review (from section two)*
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155
Matrix 2c. Depression
Strategy Activities to relieve boredom / distract AAT Aromatherapy / massage or touch Behaviour management Cognitive stimulation Counselling Environmental manipulation Light therapy Music / music therapy Physical exercise / activity Reality orientation Reminiscence / reminscence therapy MSS TENS Validation / validation therapy
Organsiation Alzheimers Society (UK) Alzheimer‟s Association (USA) Alzheimer‟s Australia Alzheimer* Europe Review (from section two)*
Matrix 2d. Hallucinations
Strategy Activities to relieve boredom / distract AAT Aromatherapy / massage or touch Behaviour management Cognitive stimulation Counselling Environmental manipulation Light therapy Music / music therapy Physical exercise / activity Reality orientation Reminiscence / reminscence therapy MSS TENS Validation / validation 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 relieve boredom / distract AAT Aromatherapy / massage or touch Behaviour management Cognitive stimulation Counselling Environmental manipulation Light therapy Music / music therapy Physical exercise / activity Reality orientation Reminiscence therapy MSS TENS Validation / validation therapy
Organsiation Alzheimers Society (UK) Alzheimer‟s Association (USA) Alzheimer‟s Australia Alzheimer Europe Review (from section two)
Matrix 2f. Wandering
Strategy Activities to relieve boredom / distract AAT Aromatherapy / massage or touch Behaviour management Cognitive stimulation Counselling Environmental manipulation Light therapy Music / music therapy Physical exercise / activity Reality orientation Reminiscence therapy MSS TENS Validation / validation therapy
Organsiation Alzheimers Society (UK) Alzheimer‟s Association (USA) Alzheimer‟s Australia Alzheimer Europe Review (from section two)
Leeds Institute of Health Sciences July 2008
157 REFERENCES References (studies/papers included in review) Bates J, Boote J, Beverley C. Psychosocial interventions for people with a milder dementing illness: a systematic review. J Adv Nurs. 2004 Mar;45(6):644-58. Cameron M, Longeran E, Lee H. Transcutaneous Electrical Nerve Stimulation (TENS) for Dementia. Cochrane Database Syst Rev. 2003(3). Chung JCC, Lai CKY. Snoezelen for dementia. Cochrane Database Syst Rev. 2002(4). Clare L, Woods RT. Cognitive rehabilitation and cognitive training for earlystage Alzheimer's disease and vascular dementia. Cochrane Database Syst Rev. 2003(4). Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. Am J Geriatr Psychiatry. 2001;9(4):361-81. Diamond B, Johnson S, Torsney K, Morodan J, Prokop B, Davidek D, et al. Complementary and alternative medicines in the treatment of dementia: an evidence-based review. Drugs Aging. 2003;20(13):981-98. Eggermont LH, Scherder EJ. Physical activity and behaviour in dementia: A review of the literature and implications for psychosocial intervention in primary care. Dementia: The International Journal of Social Research and Practice. 2006 Aug;5(3):411-28. Filan SL, Llewellyn-Jones RH. Animal-assisted therapy for dementia: A review of the literature. Int Psychogeriatr. 2006;18(4):597-611. Forbes D, Morgan DG, Bangma J, Peacock S, Adamson J. Light Therapy for Managing Sleep, Behaviour, and Mood Disturbances in Dementia. Cochrane Database Syst Rev. 2004(2). Grandmaison E, Simard M. A critical review of memory stimulation programs in Alzheimer's disease. J Neuropsychiatry Clin Neurosci. 2003;15(2):130-44. Hermans DG, Htay UH, McShane R. Non-pharmacological interventions for wandering of people with dementia in the domestic setting. Cochrane Database Syst Rev. 2007(1):CD005994.
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158 Kim S, Song HH, Yoo SJ. The effect of bright light on sleep and behavior in dementia: an analytic review. Geriatr Nurs. 2003;24(4):239-43. Lancioni GE, Cuvo AJ, O'Reilly MF. Snoezelen: an overview of research with people with developmental disabilities and dementia. Disabil Rehabil. 2002;24(4):175-84. Livingston G, Johnston K, Katona C, Paton J, Lyketsos CG. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry. 2005 Nov;162(11):1996-2021. Lou M. The use of music to decrease agitated behaviour of the demented elderly: the state of the science. Scand J Caring Sci. 2001;15(2):165-73. Neal M, Barton Wright P. Validation therapy for dementia. Cochrane Database Syst Rev. 2003(3). Nugent N. Agitated behaviours in Alzheimer's Disease and related disorders: Music and music therapy research. Australian Journal of Music Therapy Vol 13 2002, 38-50. 2002. Peng WN, Zhao H, Liu ZS, Wang S. Acupuncture for vascular dementia. Cochrane Database Syst Rev. 2007(2):CD004987. Penrose FK. Can exercise affect cognitive functioning in Alzheimer's disease? A review of the literature. Activities Adapt Aging. 2005;29(4):15-40. Price JD, Hermans DG, Grimley Evans J. Subjective barriers to prevent wandering of cognitively impaired people. Cochrane Database Syst Rev. Chichester, UK: John Wiley & Sons, Ltd 2001. Robinson L, Hutchings D, Corner L, Beyer F, Dickinson H, Vanoli A, et al. A systematic literature review of the effectiveness of non-pharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use. Health Technology Assessment. 2006 Aug;10(26):iii, ix-108. Robinson L, Hutchings D, Dickinson HO, Corner L, Beyer F, Finch T, et al. Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review. Int J Geriatr Psychiatry. 2007 Jan;22(1):9-22. Sherratt K, Thornton A, Hatton C. Music interventions for people with dementia: a review of the literature. Aging Ment Health. 2004 Jan Jan;8(1):3-12.
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159 Sitzer DI, Twamley EW, Jeste DV. Cognitive training in Alzheimer’s disease: a meta analysis of the literature. ACTA Psychiatrica Scandinavica. 2006; 114: 7590 Skjerve A, Bjorvatn B, Holsten F. Light therapy for behavioural and psychological symptoms of dementia. Int J Geriatr Psychiatry. 2004 Jun;19(6):516-22. Spira AP, Edelstein BA. Behavioral interventions for agitation in older adults with dementia: an evaluative review. Int Psychogeriatr. 2006 Jun Jun;18(2):195-225. Sung HC, Chang AM. Use of preferred music to decrease agitated behaviours in older people with dementia: a review of the literature. J Clin Nurs. 2005 Oct;14(9):1133-40. Thorgrimsen L, Spector A, Orrell M. The use of aromatherapy in dementia care: A review. Journal of Dementia Care. 2006;14(2):33-6. Thorgrimsen L, Spector A, Wiles A, Orrell M. Aroma therapy for dementia. Cochrane Database Syst Rev. 2003(3):CD003150. Verkaik R, van Weert JCM, Francke AL. The effects of psychosocial methods on depressed, aggressive and apathetic behaviors of people with dementia: a systematic review. Int J Geriatr Psychiatry. 2005 Apr;20(4):301-14. Viggo Hansen N, Jorgensen T, Ortenblad L. Massage and touch for dementia. Cochrane Database Syst Rev. 2006(4). Vink AC, Birks JS, Bruinsma MS, Scholten RJP. Music therapy for people with dementia. Cochrane Database Syst Rev. 2003(4). Warner J, Butler R, Wuntakal B. Dementia. Clin Evid 2006:1361-90. Watson R, Green SM. Feeding and dementia: a systematic literature review. Journal of Advanced Nursing. 2006; 54(1); 86-93
Woods B, Spector A, Jones C, Orrell M, Davies S. Reminiscence therapy for dementia. Cochrane Database Syst Rev. 2007(4).
Dementia Organisation (websites included in Section Three) Alzheimer’s Society http://www.alzheimers.org.uk/site/ Leeds Institute of Health Sciences July 2008
160 Alzheimer Australia http://www.alzheimers.org.au/ Alzheimer Association http://www.alz.org/index.asp Alzheimer Europe http://www.alzheimer-europe.org/ References (report references) Baker, R., Bell, S., Assey, J., et al. 1998. A Randomised Controlled Trial of the Snoezelen Mulit-sensory Environment for Patients with Dementia. Dorset Healthcare NHS Trust: Bournemouth
Baker, R., Bell, S., Baker, E., Gibson, S., Holloway, J., Pearce, R., Dowling, Z., Thomas, P., Assey, J., Wareing L.A. 2001. A randomised controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia. British Journal of Clinical Psychology; 40, 81-96
Baker, R., Holloway, J., Holtkamp, C.M.M., Larsson, A., Hartman, L.C., Pearce, R., Scherman, B., Johansson, S., Thomas, P.W., Wareing L.A., Owens, M. 2003. Effects of multi-sensory stimulation for people with dementia. Issues and Innovation in Nursing Practice. 43(5), 465-477
Bianchetti A., Trabucchi, M. 2004. Behavioural and Psychological Symptoms of Dementia: Clinical Aspects. Neuroscience Research Communications. 35(3), 173-183
Clare L, Woods RT. 2003. Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia. Cochrane Database Syst Rev. 2003(4).
Department of Health (2004). At least 5 a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. DH.
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161 Griffiths, C., Rooney, C. 2006. Trends in Mortality from Alzheimer’s Disease, Parkinson’s Disease and Dementia in England and Wales. Health Statistics Quarterly. 30, 6-14 Groene, R.W. 1993. Effectiveness of music therapy 1:1 intervention with indivudals having senile dementia of Alzheimer’s type. Journal of Music Therapy. 30(3); 138-157
International Psychogeriatric Association. 2002 Behaviour and Psychological Symptoms of Dementia (BPSD) Educational Pack (http://www.ipaonline.org/ipaonlinev3/ipaprograms/bpsdarchives/bpsdrev/toc.asp)
Knapp, M., Prince, M., Albanese, E., Banerjee, S., Dhanasiri, S., Fernandez, J.L., Ferri, C., McCrone, P., Snell. T., Stewart, R. 2007. Dementia UK, Alzheimer's Society, London.
Koger, S., Brotons, M. 2000. Music Therapy for Dementia Symptoms. Cochrane Database of Systematic Reviews Lavretsky, H and Nguyen, L.H. 2006. Innovation: Geriatric Psychiatry: Diagnosis and Treatment of Neuropsychiatric Symptoms in Alzheimer’s Disease. Psychiatric Services. 57: 617-619 McNamara, C., Kempenaar, L. 2001. A Pilot Study for Specific Sensory Stimulation with Multi-sensory Stimulation with People with Dementia in a Community Setting. Ayreshire & Arran Primary Care NHS Trust: Ayr
National Institute of Clinical Excellence. 2006. Public Health Guidance: Development Process and Methods. March 2006: London
Paton, D. 2006. Reality Orientation: Its Use and Effectiveness Within Older Person Mental Health Care. Journal of Clinical Nursing; 15, 1439-1448 Leeds Institute of Health Sciences July 2008
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Peoples, M. 1982. Validation Therapy Versus Reality Orientation as Treatment for Disorientated Institutionalised Elderly. Masters Dissertation, College of Nursing, University of Akron
Quayhagen, M.P., Quayhagen, M., Corbeil, R.R., Hendrix, R.C., Jackson, J.E., Snyder, L., Bower, D. 2000. Coping with dementia: evaluation of four nonpharmacological interventions. Int Psychgeriatric. 12; 249-265
Quayhagen, M.P., Quayhagen, M., Corbeil, R.R., Roth, P.A., Rodgers, J.A. 1995. A dyaic remediation program for care recipients with dementia. Nursing Research. 44; 153-159
Rayner, A.V., O’Brien, J.G., Schoenbachler B. 2006. Behaviour Disorders of Dementia: Recognition and Treatment. American Family Physician. 73(4) 647652
Robb, S., Stegman, C.E., Wolanin, M.O. 1986. No Research Versus research with Compromised Results: A Study of Validation Therapy. Nursing Research. 35(2); 113-8 Smallwood C. The Role of Complementary and Alternative Medicine in the NHS. London: FreshMinds, 2005. accessed October 7, 2005. Toseland, R.W., Diehl, M., Freeman, K., Manzanares, T., Naleppa, M., McCallion, P. 1997. The Impact of Validation Group Therapy on Nursing Home Residents with Dementia. Journal of Applied Gerontology. 16(1); 31-50
van Weert, J.C., van Dulman, A.M., Spreeuwenberg, P.M.M., Ribbe, M.W., Bensing, J.M. 2005. Effects of Snoezelen, integrated in 24h dementia care, on Leeds Institute of Health Sciences July 2008
163 nursing-patient communication during morning care. Patient Education and Counselling. 58; 316-326
Warner J, Butler R, Wuntakal B. Dementia. 2006. Clinical Evidence. 1361-90
Wolf SL, O'Grady M, Easley KA, Guo Y, Kressig RW, Kutner M. 2006. The influence of intense Tai Chi training on physical performance and hemodynamic outcomes in transitionally frail, older adults. J Gerontol A Biol Sci Med Sci. 2006 Feb;61(2):184-9.
World Health Organsiation. (2004) Global Strategy on Diet, Physical Activity and Health (http://who.int/hpr/global.strategy.shtml). Yuhas, N., McGowan, B., Fontaine, T., Czech, J., Gambrell-Jones, J. 2006. Interventions for Disruptive Symptoms of Dementia. Journal of Psychosocial Nursing. 44(11) 34-42.
Leeds Institute of Health Sciences July 2008
164 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$)).tw. 11. dolls.tw. Leeds Institute of Health Sciences July 2008
165 12. or/1-11 13. exp *psychotherapy/ 14. (reality$ 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$)).tw. 5. exp kinesiotherapy/ 6. vocational rehabilitation/ 7. Recreational Therapy/ 8. exp sensory stimulation/ or auditory stimulation/ 9. exp psychotherapy/ Leeds Institute of Health Sciences July 2008
166 10. ((art$ 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$).ti. 36. 34 or 35 37. or/1-28 38. 37 and 33 and 36 39. limit 38 to yr="2001 - 2008" Leeds Institute of Health Sciences July 2008
167 4. OVID MEDLINE 1996 – Nov 2007 1. exp psychotherapy/ 2. (reality adj2 orientat$).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 Leeds Institute of Health Sciences July 2008
168 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$).ti. 56. 54 or 55 57. 53 and 56 58. limit 57 to yr="2001 - 2007"
5. OVID PSYCHINFO 2000 – Nov 2007 1. exp Occupational Therapy/ 2. exp *creative arts therapy/ 3. exp *exercise/ 4. exp *games/ 5. exp *psychodrama/ 6. exp *phototherapy/ 7. exp *vocational rehabilitation/ Leeds Institute of Health Sciences July 2008
169 8. bibliotherap$.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/ Leeds Institute of Health Sciences July 2008
170 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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171 APPENDIX TWO (data extraction template)
Methodology checklist A.1 Methodology checklist: systematic reviews and metaanalyses
Study identification
Include author, title, reference, year of publication
Guideline topic Checklist completed by: SECTION 1: INTERNAL VALIDITY In a well-conducted systematic review:
Key question no:
In this study this criterion is: (Circle one option for each question)
Well covered Not addressed The study addresses an appropriate Adequately addressed Not reported and clearly focused question. Poorly addressed Not applicable Well covered Not addressed 1.2 A description of the methodology used Adequately addressed Not reported is included. Poorly addressed Not applicable Well covered Not addressed 1.3 The literature search is sufficiently Adequately addressed Not reported rigorous to identify all the relevant Poorly addressed Not applicable studies. Well covered Not addressed 1.4 Study quality is assessed and taken Adequately addressed Not reported into account. Poorly addressed Not applicable Well covered Not addressed 1.5 There are enough similarities between 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
1.1
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