a systematic review of non-drug treatments for dementia
TRANSCRIPT
Leeds Institute of Health SciencesFACULTY 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 BuildingUniversity of Leeds101 Clarendon RoadLeeds, United KingdomLS2 9LJ
www.leeds.ac.uk/lihs
CONTENTS Page
EXECUTIVE SUMMARY 4
ACKNOWLEDGEMENT 11
SECTION ONE 12Background 12Aim 15Methodology 16Literature Search 16Quality Appraisal 18Dementia Organisation 19
SECTION TWO 20Review of Effectiveness 20Interventions 20Symptoms 21Interventions and Symptoms 22Overview of Papers 23Interventions 23Acupuncture 23Animal Assisted Therapy 24Aromatherapy 27Behaviour Management 29Cognitive Stimulation Therapy/Cognitive Training 31Counselling 35Environmental Manipulation 35Light Therapy 37Massage/Touch 39Music / Music Therapy 41Physical Activity/Exercise 47Reality Orientation 50Reminiscence Therapy 51Snoezelen/Multi-sensory Stimulation 53TENS 57Validation Therapy 58
SECTION THREE 61Introduction 61
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Interventions 62Acupuncture 62Animal Assisted Therapy 63Aromatherapy and Massage 65Behaviour Management 70Cognitive Stimulation Therapy/Cognitive Training 71Counselling 72Environmental Manipulation (including lighting) 72Music / Music Therapy 76Physical Activity/Exercise 79Reality Orientation 83Reminiscence Therapy 84Snoezelen/Multi-sensory Stimulation 85TENS 86Validation Therapy 87Symptoms or Behaviour 89Creating a Relaxing Environment 90Activities 92Aggression 95Agitation or Anxiety 97Depression 100Hallucinations 103Sleeplessness 105Wandering 106
SECTION FOUR 108Conclusion and Implications for Carers 108Implications for Future Research 111Implications for Service providers and Commissioners
113
REFERENCES References (studies/papers included in review)
157References (report references) 160
APPENDIX ONE (search strategies) 164APPENDIX TWO (data extraction template) 171
TABLES, MATRICES, BOXES
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Table 1: Acupuncture 116Table 2: Animal Assisted Therapy 117Table 3: Aromatherapy 119Table 4: Behaviour Management 121Table 5: Cognitive Stimulation Therapy/Cognitive Training 123Table 6: Counselling 126Table 7: Environmental Manipulation 127Table 8: Light Therapy 129Table 9: Massage/Touch 132Table 10: Music /Music Therapy 134Table 11: Physical Activity/Exercise 140Table 12: Reality Orientation 144Table 13: Reminiscence Therapy 145Table 14: Snoezelen/Multi-sensory Stimulation 147Table 15: TENS 150Table 16: Validation Therapy 151Table 17: Systematic reviews that did not identify 153any studies for inclusion Matrix 1: Interventions and Symptoms Evidence Assessment 114 Matrix 2: Interventions, Behaviour/Symptoms, Oganisation 154Box 1: Reasons for Exclusion from the Review 18Box 2:Types of Symptoms 21Box 3: Interventions and Symptoms 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 non-drug approaches for dementia, that they might try or that
they could try to access.
Using a two part process, initially a systematic review was carried
out in order to addresses the following questions:
What non-drug treatments work and what do they work for?
What non-drug treatments might work and what for?
What non-drug treatments do not work?
The second part of the process searched the websites of four
national (UK, USA and Australia) and international (Europe)
dementia organisations to identify recommendations or suggestions
for non-drug approaches for dementia. In each case the strategies
identified from the websites were aligned with the non-drug
treatments identified in the systematic review to produce a series of
suggestions or ideas for informal carers about non-drug approaches
for dementia, that they might try or access.
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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Methodology
Seven electronic databases were searched for systematic reviews
published since 2001. Screening of retrieved papers was two
staged. Titles and abstracts were first screened. The full papers of
those studies that passed this initial process were then screened.
The studies included in the review went on to a data extraction
process and quality assessment. Each study was given a rating of +
+ (high) + or – (low). Studies were classified according to
intervention. Within each category evidence was provided using a
narrative synthesis, supported by evidence tables, drawing out the
key features of each review.
Criteria for inclusion of dementia organisation was that they be
national/international organisations and that website was freely
available, written in English and includes fact sheets, tips or
suggestions for informal carers. Search of the websites was carried
out by intervention type (as identified in the systematic review) and
by behaviour/symptom type (again as identified in the systematic
review). Where the web pages included links to, or referred to,
additional pages or other sites these were also followed. Using
content analysis the recommendations were grouped by
intervention type and behaviour/symptom type.
Thirty five papers were included in the systematic review
representing 33 studies. Four dementia organisations were included
in the second part of the process.
Results
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Effectiveness
The evidence from the systematic review suggests three different
interventions are effective for symptoms of dementia: Music or
music therapy, hand massage or gentle touch and physical activity
or exercise. Music or music therapy had potential benefits for
behavioural and psychological symptoms (including aggression,
agitation and wandering) and cognition; massage for behavioural
and psychological symptoms, in particular agitation; and physical
activity for behavioural and psychological symptoms (mood, sleep
and wandering). However even for these interventions the evidence
is mixed or limited. For example, within the papers exploring music
or music therapy methodological limitations were highlighted that
included weak study designs and small sample numbers. Similarly
evidence was presented for the use of massage or touch therapies
and whilst there is evidence to suggest massage or touch therapies
do work in a reducing agitation in the short term and can help with
eating there was no conclusive evidence that massage reduces
wandering, anxiety or aggressiveness. The evidence from the
review dovetailed with the information given by the dementia
organisations. All the dementia organisations suggested strategies
that include music, physical activity or exercise and touch or
massage.
In respect of non-drug treatments that might work, the majority of
interventions fell into this category due to inconclusive results
(Animal Assisted Therapy, Aromatherapy, Behaviour Management,
Cognitive Stimulation, Environmental Manipulation, Light Therapy,
Reality Orientation, Reminiscence Therapy, Multi-sensory
Stimulation (MSS), Transcutaneous Electric Nerve Stimulation
(TENS) and Validation Therapy). The lack of firm evidence arose
primarily through conflicting results and weakness in study design.
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The implication for carers is that whilst some of these interventions
might be useful in managing symptoms of dementia the evidence is
not strong enough to support their use. However, some of the
interventions in this group formed the backbone of the suggested
coping/prevention strategies included in the dementia
organisations’ websites.
Within the systematic review there was no evidence to suggest
beneficial effects for two interventions, acupuncture and
counselling. This was due to a dearth of studies that fit the review
papers’ inclusion criteria. No randomised controlled trials were
found for use of acupuncture for symptoms of dementia (Peng et al,
2007) and in line with the paucity of evidence none of the dementia
organisations suggested its use.
Counselling was included in one paper (Bates et al, 2004). Whilst no
evidence was demonstrated for improvements in cognitive function
(recall logic, memory and learning) all the dementia organisations
referred to counselling and/or cognitive behaviour therapy in the
treatment of depression for people with dementia. Although
Alzheimer Europe note, any kind of therapy which relies on verbal
communication will only be suitable for a small number of people
suffering from dementia or those in the early stages3
What strategies might carers try?
The focus of the strategies is behavioural and psychological
symptoms of dementia. The strategies are an amalgamation of the
findings from the systematic review and recommendations or
suggestions from dementia organisations. The strategies are
generic in as much as they do not apply to one specific type of
dementia.
3 http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE
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General strategies:
To reduce behavioural and psychological symptoms of dementia
create a relaxing environment paying attention to noise levels,
lighting, music, other sensory stimulants like massage and touch.
Pets may also have a calming effect
In some cases difficult behaviours can be headed off or coped
with by using an activity which provides a distraction from the
behaviour or stops boredom. Carers might try music activities,
activities with pets such as walking or petting the dog, sensory
stimulation using massage or other touch therapies or activities
that involve reminiscing. Physical activities can help use up spare
energy, and provide a sociable activity giving routine and
structure to the day
The following are activities or techniques that carers might like to
try access locally. At the end of each suggestion the behaviour for
which it might be beneficial is given in brackets.
Training course for carers:
Behaviour management techniques. Carers can
also ask for an assessment of key factors that may
improve challenging behaviour in those they are
caring for (aggression, agitation, anxiety,
depression, wandering)
Techniques of validation therapy (aggression,
depression, hallucinations)
o Interventions for the person with dementia:
Animal Assisted Therapy (aggression, agitation,
anxiety, depression)
Bright light therapy (agitation, sleeplessness)
Music therapy (aggression, agitation, anxiety,
depression, hallucinations, wandering)
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Multi-sensory stimulation (aggression, depression,
wandering)
Reminiscence therapy (agitation, anxiety,
depression, hallucinations)
Counselling or cognitive behaviour therapy
(depression)
Cognitive stimulation therapy (depression)
Reality orientation (depression)
Techniques or strategies that carers may try at home include:
Having a pet in the home to encourage relaxation, to provide a
distraction, provide comfort, stimulate conversation and provide
the opportunity for exercise and social contact
Use aromas (for example lavender oil) to create a calm
environment
Try massage or touch to soothe, to distract, encourage
interaction, provide reassurance, encourage eating, or reduce
wandering
Create a calming environment by removing competing noises,
ensuring lighting is adequate, using nightlights for reassurance
Try using music as the focus of activity, sharing music together,
encouraging singing clapping or even dancing
Use background music to help create a calming environment
Try different forms of physical activity. This can be formal classes
such as tai chi or informal activities like housework
Try activities that involve reminiscing e.g. looking at old photos
or old books or making a family scrapbook
Conclusions
Overall the studies included in the reviews were characterised by
weak study designs and small sample sizes. Indeed three reviews
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were unable to identify any studies of sufficient quality to assess.
Many of the reviews included single person case studies or studies
of less than five people. Whilst it is not possible to generalise about
the effectiveness of different interventions many pointed to
potential benefits from the intervention being assessed.
Many of the studies included were based in community residential
settings (for example, in nursing homes). Given the increasing
number of people now caring for people with dementia in their own
home there is a clear need to ensure that research is transferable to
this setting. Indeed, the International Psychogeriatric Association
(IPA) note that further research is need to explore the relationship of
behavioural and psychological symptoms of dementia to the
environments in which they occur (IPA, 2002, p7)
Taken together, whilst the volume of studies in this area is
encouraging the review points to the need for large, well designed,
randomised controlled studies rather than the seemingly piecemeal
approach taken at present.
The suggestions or recommendations made by dementia
organisations appear to be based on existing research evidence
together with suggestions from carers themselves about what works
for them. The focus of these suggestions lies in behaviour and
psychological symptoms. This is unsurprising given that virtually all
patients with dementia will develop changes in behaviour as the
disease progresses (Rayner et al, 2006, p647). Whilst the suggested
strategies appear to be general, rather than specific across many
behaviours the consensus opinion is that the incidence of distress
can be ameliorated by a calming environment, structured activities
and redirection or distraction (Lavretsky and Nguyen, 2006).
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Whilst carers can apply some of the 16 interventions in the home
setting at little or no cost to health or social care services (for
example, playing favourite music), others are likely to require
training (for example in hand massage) or instruction (for example,
in appropriate exercise routines). Both service providers and
commissioners should explore current and future provision of more
structured group activities for people with dementia in line with the
evidence presented; in particular the provision of group music
therapy and group exercise activities that meet the needs of both
the person with dementia and their carer.
ACKNOWLEDGEMENT
"This work was made possible by a generous bequest from the
estate of Gilda Massari, whose wish was to fund research that
produced practical benefit for the carers of people with Alzheimer's
disease and related conditions. A version for carers is available
from The Dementia Services Development Centre, University of
Stirling, [email protected] "
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SECTION ONE
Background
Dementia is used to describe a collection of symptoms, including a
decline in memory, reasoning and communication skills, and a
gradual loss of skills needed to carry out daily activities (Knapp et
al, 2007); it is a non-reversible deterioration in memory, executive
function and personality (Warner et al, 2006).
In the UK it is estimated that there are 700,000 people with
dementia representing around one person in every 88 (1.1%) of the
entire population (Knapp et al, 2007). This figure is set to increase
to over 940,110 by 2021 (Knapp et al, 2007). Dementia is most
common in older people; in the UK one in five people over the age
of 80 years and one in 20 over the age of 65 years has a form of
dementia (Knapp et al, 2007).
Typically dementia is reported under four categories: Alzheimer’s
disease, vascular dementia, Lewy body dementia and frontal
temporal dementia. All are characterised by problems with cognitive
functioning and those with dementia are likely to experience
behavioural and psychological symptoms (Warner et al, 2006).
Alzhiemer’s disease is the most prevalent type of dementia; in the
UK Alzheimer’s accounts for around 6 out of 10 cases of dementia4.
It is a progressive and eventually fatal disease (Yuhas et al, 2006,
p35) of unknown etiology with characteristic neuropathological and
neurochemical features5. It is characterised by an insidious onset
and slow deterioration and involves impairments of speech, motor,
personality and executive function (Warner et al, 2006). Alzheimer’s
typically affects older people but can begin in younger individuals.
4 http://www.patient.co.uk/showdoc/23068719/5 http://www.who.int/classifications/apps/icd/icd10online/
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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 disease6.
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
6 http://www.who.int/classifications/apps/icd/icd10online/
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symptoms may appear at any stage of the illness. Behaviours that
may be present include nocturnal confusion and wandering (Yuhas
et al 2006). Progression may be slowed through control of
underlying risk factors such as blood pressure (Knapp et al, 2007).
Lewy body dementia is a progressive dementia identified by
abnormal structures in the brain cells called Lewy bodies (Yuhas et
al 2006). Tiny spherical protein deposits develop inside the nerve
cells in the brain interrupting the brain’s normal functioning,
affecting memory, concentration and language (Knapp et al, 2007).
This type of dementia is characterised by fluctuation of symptoms,
the presence of early and prominent visual hallucinations and
Parkinsonian symptoms (slow movement, bending slightly forward
and shuffling when walking) (Yuhas et al 2006). Progression is more
rapid than Alzheimer’s disease but short term memory is usually
good. Those with this type of dementia can show marked
fluctuations in alertness or cognition from hour to hour or week to
week – characterised by confusion during which it is difficult to
concentrate and complete tasks. Likely psychotic symptoms include
paranoia, delusions and hallucinations which can be disruptive.
People with Lewy bodies dementia are at risk of falls because of lack
of an effective righting reflex and may experience restless leg
syndrome which can interfere with sleep (Yuhas et al 2006).
Frontal temporal dementia is typically exhibited in those with a
group of rare neurological disorders affecting the frontal and
anterior temporal lobes of the brain; these include Pick’s disease,
frontal lobe degeneration, and dementia associated with motor
neuron disease (Yuhas et al 2006). It is likely to affect people under
65 and is characterised by gradual onset of changes in personality,
social behaviour and language, dependent on whether damage has
occurred in the left side (language) or right side (behaviour) of the
front of the brain (Yuhas et al 2006). The later stages are
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characterised by difficulties with speech and language, memory loss
and oral fixations. Behavioural and psychological disturbances are
common (Yuhas et al 2006).
In the UK there is increasing focus on dementia. A recent report
from the House of Commons Committee of Public Accounts
acknowledged that dementia, despite its financial and human
impact, has not received the same priority status as other diseases.
It is estimated that in England alone late-onset dementia costs some
£14.3 billion per year. This estimate includes the cost of care home
accommodation (£5.72 billion, 40%) and an estimated saving to the
taxpayer of £5.29 billion (37%) from the contribution made by
informal carers (the NHS and social care make up the remainder;
£1.14 billion 8% and £2.15 billion 15% respectively)7.
The House of Commons report highlights the heavy burden carried
by those caring for relatives with dementia at home. Indeed
informal carers8 deliver most of the care to people with dementia in
the UK and many are elderly and frail themselves9. A National
Dementia Strategy is planned for 200810.
Aim
The aim of this report is to help informal carers who want ideas
about non-drug approaches for dementia, that they might try or that
they could try to access.
Using a two part process, initially a systematic review was carried
out in order to addresses the following questions:
7 http://www.publications.parliament.uk/pa/cm200708/cmselect/cmpubacc/228/228.pdf8 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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What non-drug treatments work and what do they work for?
What non-drug treatments might work and what for?
What non-drug treatments do not work?
The second part of the process searched the websites of four
national (UK, USA and Australia) and international (Europe)
dementia organisations to identify recommendations or suggestions
for non-drug approaches for dementia. In each case the strategies
identified from the websites were aligned with the non-drug
treatments identified in the systematic review to produce a series of
suggestions or ideas for informal carers about non-drug approaches
for dementia, that they might try or access.
Methodology
The systematic review has been carried out by a team from the
Institute of Health Sciences, University of Leeds.
Literature Search
The search strategy was developed by the review team at the
University of Leeds. Literature searches of electronic databases and
websites were then carried out. Comprehensive searches of the
following databases were carried out on 7th November 2007:
AMED (via OVID host)
CINAHL (via OVID host)
EMBASE (via OVID host)
MEDLINE (via OVID host)
PSYCINFO (via OVID host)
Cochrane Library of Systematic Reviews (via Wiley host)
DARE (via Wiley host)
The search strategies used can be found in Appendix 1.
Inclusion Criteria
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1. Systematic reviews only (not reviews) including at least one
randomised controlled trial of a non-drug intervention
2. English language
3. Non-drug treatments
4. The primary purpose of the review is to evaluate the
effectiveness or efficacy evidence of one or more non-drug
treatments for dementia
5. Reviews published from 2001 onwards
Exclusion Criteria
1. Management of dementia in acute settings
2. Management of dementia in long term care
facilities/residential care settings
3. Assessment of dementia
4. Screening for dementia
5. Prevention of dementia
6. Guidelines for dementia
7. Herbal remedies/vitamin supplements
8. Generic reviews in gerontology
9. Interventions for caregivers (this refers to interventions for
carers per se rather than interventions that carers can implement to
help the person they care for)
The search yielded 784 unique references. Two stages of screening
were used to determine which studies should be included in the
review. Titles and abstracts of all 784 references were first
screened. This first screening identified 114 potentially relevant
papers. Full paper screening of the 114 references identified 35
papers to be included in the review representing 33 studies. Of the
remaining, six provided background detail, 71 were excluded, and
two were unobtainable in the time available. Reasons for exclusion
are shown in box 1.
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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
57
Not English language 4The primary purpose of the review is not to evaluate the effectiveness or efficacy evidence of one or more non-drug treatments for dementia
6
Guidelines 2Not received in time to be included 2Précis of a review only 1Withdrawn 1Background only 6Total 79
Quality Appraisal
Data relating to the scope of this review was extracted from each
study using the National Institute of Clinical Excellence (NICE) data
extraction template (NICE 2006). Methodological checklists (NICE
2006) were applied to each study to determine the quality of each
study. The checklist states that in a well-conducted systematic
review:
The study addresses an appropriate and clearly
focussed question
A description of the methodology used is included
The literature search is sufficiently rigorous to identify
all relevant studies
Study quality is assessed and taken into account
There are enough similarities between the studies
selected to make combining them reasonable (NICE
2006, p112)
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Each study was given a rating of ++ (high) + or – (low). Studies
assessed ++ are those in which all or most of the above criteria on
the checklist are fulfilled. Where the criteria are not fulfilled the
conclusions the review comes to are thought very unlikely to alter.
For those assessed + some of the above criteria is fulfilled. Those
not fulfilled or adequately described are thought unlikely to alter the
review’s conclusions. A rating of – is applied where few or none of
the above criteria are fulfilled. Had they been fulfilled the review’s
conclusions are likely or very likely to alter.
Studies were categorised according to intervention type. Within
each of these categories evidence is provided using a narrative
synthesis, supported by evidence tables, drawing out the key
features of each study. Evidence is provided in a hierarchy with
higher quality studies ranked first in the evidence tables.
Dementia Organisations
Criteria for inclusion of dementia organisation was that they be
national/international organisations and that website was freely
available, written in English and includes fact sheets, tips or
suggestions for informal carers. Search of the websites was carried
out by intervention type (as identified in the systematic review) and
by behaviour/symptom type (again as identified in the systematic
review). Where the web pages included links to, or referred to,
additional pages or other sites these were also followed.
Using content analysis the recommendations were grouped by
intervention type and behaviour/symptom type. The search was
stopped at four dementia organisations as saturation was achieved.
The organisations and website address are shown below.
Four national/international dementia websites were included:
Alzheimer’s Society (UK) http://www.alzheimers.org.uk/site/
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Alzheimer’s Association (USA) http://www.alz.org/index.asp
Alzheimer’s Australia (Australia)
http://www.alzheimers.org.au/index.cfm
Alzheimer Europe http://www.alzheimer-europe.org/
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SECTION TWO
Review of Effectiveness
The review identified 35 papers representing 33 studies (2 papers
reported on the same studies) which met the inclusion criteria. In
addressing the review questions:
What non-drug treatments work and what do they work for?
What non-drug treatments might work and what for?
What non-drug treatments do not work?
Interventions
The studies were grouped by intervention into 16 key areas:
Acupuncture
Animal Assisted Therapy
Aromatherapy
Behaviour Management
Cognitive Stimulation Therapy/Cognitive Training
Counselling
Environmental Manipulation
Light Therapy
Massage/Touch
Music/Music Therapy
Physical Activity/Exercise
Reality Orientation
Reminiscence Therapy
Snoezelen/Multi-sensory Stimulation
TENS
Validation Therapy
Symptoms
The symptoms of dementia addressed in the papers include in the
review were varied and ranged from the specific to the general. In
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order to make sense of these, each has been grouped into one of
the three main types symptoms typically displayed by people with
dementia (see box 2 below). The three main types of symptom are:
loss of cognitive function, impairment of the ability to perform
activities of daily living (ADLs) and abnormal behaviour11. Loss of
cognitive function often manifests itself in memory loss whilst
impaired functional ability can affect, for example, a person’s ability
to get dressed or brush their teeth. Abnormal behaviour covers both
behavioural and psychological symptoms. Indeed the term
behavioural and psychological symptoms (BPSD) is used to describe
the non-cognitive manifestation of dementia (Bianchetti and
Trabucchi, 2004). The groupings used by Bianchetti and Trabucchi
have been used inform the classification of symptoms.
Box 2: Types of Symptoms
Cognitive Ability Ability to perform
activities of daily living
Behavioural and psychological
symptoms
Cognitive FunctionCommunication
LearningMemoryRecall
Functional AbilityQuality of
Life/Well-being
AggressionAgitationAnxietyApathy
BehaviourDepression
Emotional and Behavioural ResponsesInappropriate Behaviour
MoodNeuropsychiatric
SymptomsNutrition
Psychological SymptomsSleep
Social BehaviourWandering
Interventions and Symptoms
11 http://www.searo.who.int/en/Section1174/Section1199/Section1567/Section1823_8057.htm
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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 SmptomsCognitive Ability Ability to perform
activities of daily living
Behavioural and psychological
symptomsCognitive
Stimulation Therapy/Cognitiv
e TrainingCounselling
Light TherapyMusic/Music
TherapyPhysical
Activity/ExerciseReality
OrientationReminiscence
TherapySnoezelen/Multi-
sensory Stimulation
TENSValidation Therapy
Cognitive Stimulation
Therapy/Cognitive TrainingPhysical
Activity/ExerciseReality OrientationSnoezelen/Multi-
sensory Stimulation
Animal Assisted Therapy
AromatherapyBehaviour
ManagementCognitive
Stimulation Therapy/Cognitiv
e TrainingEnvironmental ManipulationLight Therapy
Massage/TouchMusic/Music
TherapyPhysical
Activity/ExerciseReality
OrientationReminiscence
TherapySnoezelen/Multi-
sensory Stimulation
TENSValidation Therapy
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Overview of Papers
The majority of papers identified in this review were concerned with
dementia in a generic sense in as much as they did not identify one
type of dementia or a specific stage of dementia. The focus of the
six papers that were more specific were Alzheimer’s disease (Clare
& Woods, 2003; Grandmaison & Simar, 2003; Penrose, 2005; Sitzer
et al, 2006), vascular dementia (Clare & Woods, 2003: Peng et al,
2007) and milder dementia or early stage dementia (Clare & Woods,
2003; Bates et al, 2004). The samples within the studies typically
consisted of older people.
Overall the research studies presented within the reviews identified
were characterised by weak study designs with small sample
numbers. This meant that three of the reviews included (Hermans et
al, 2007; Peng et al, 2007; Price et al, 2001) presented their
objectives, search strategies and selection criteria but did not find
any suitable studies for inclusion in their reviews. The study
inclusion criteria for Hermans et al (2007) and Peng et al (2007)
included only randomised controlled trials; Price et al (2001) also
included controlled trials and interrupted time series. Details of
these studies are presented in tables 1 and 17. Reference is also
made to them where appropriate in the text.
Interventions
Acupuncture
Traditional acupuncture is used to treat a wide range of illnesses.12
The treatment involves fine needles being inserted through the skin
and briefly left in position. The number of needles varies but may be
only two or three13. Only one review was identified that attempted
12http://www.acupuncture.org.uk/content/AboutAcupuncture/acupuncture.html 13 http://www.medical-acupuncture.co.uk/patients/
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to explore the use of acupuncture (Peng et al, 2007). A summary of
the key characteristics of the review are given in table 1, p116.
Peng et al aimed to assess the efficacy and possible adverse effects
of acupuncture therapy for treating vascular dementia. To be
included in the review studies should be randomised controlled
trials, participants with a diagnosis of vascular dementia according
to accepted criteria, and research comparing any type of
acupuncture therapy with placebo or no intervention. The review did
not identify any studies that met the criteria and thus has not been
given a quality rating.
Summary
No evidence was identified to support the use of acupuncture for
those with vascular dementia.
Animal Assisted Therapy (AAT)
Formally AAT most commonly involves interaction between a client
and a trained animal, facilitated by a human handler, with a
therapeutic goal such as providing relaxation or pleasure, or
incorporating activities in physical therapy or rehabilitation (Filan &
Llewellyn-Jones, 2006, p598).
Thus, AAT may simply be to focus on the animal for a specified time
(for example grooming a dog or petting it). This can promote
conversation or physical activity or promote conversation about
previous pets which increases over time14. Indeed studies in the
1980s indicated that pets promoted dialogue among family
members and contributed to well-being (Wilson & Turner, 1998).
However, it is reported that the benefits of therapy pets vary a lot
by the individual15.
14 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define115 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1
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Two reviews (Filan & Lllewellyn-Jones, 2006; Cohen-Mansfield, 2001)
considered the use of animals as part of the therapeutic process for
those with dementia with the aim of reducing agitation and/or
aggression, promoting social behaviour and improving nutrition. A
summary of the key characteristic of the reviews are provided in
table 2, p117-118.
Whilst many of the studies included in the reviews consider AAT in
terms of a trained animal and therapist others consider the
presence of a dog or cat in the home (both in a residential and
private setting) either full time or for short periods of time to reduce
agitation and/or aggression and promote social behaviour. Indeed it
has been suggested that the presence of an animal can provide a
sense of meaning, diversion and serendipity; that companion
animals provide unconditional positive regard in stages of
Alzheimer’s disease where normal avenues of communication fail
(Baum & McCabe, 2003). They go on to suggest that caregivers
might also benefit from the stress reduction that results from
petting a familiar companion animal (p44).
The first review of 11 studies (Filan and Lllewellyn-Jones, 2006),
which was assessed as +, appraised studies that have investigated
whether AAT has a measurable beneficial effect for people with
dementia and specifically upon behavioural and psychological
symptoms of dementia. The study interventions included ‘pet visits’,
the introduction of a resident dog and introduction of aquaria.
Six studies within the review reported on the impact on anxiety and
aggression (of either the introduction of a dog or cat at specified
periods or a ‘resident’ dog); all report at least one significant,
positive result. Four assess the impact on social behaviour (of either
the introduction of a dog or cat at specified periods or a ‘resident’
dog); all report positive results. One study reported on the impact
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on nutrition and reports a significant increase in food intake and
monthly resident weight when a fish tank is introduced in the dining
area of a nursing home. The review concludes that AAT appears to
offer promise as a psychosocial intervention for people with
dementia. However, the optimal frequencies and duration of AAT
sessions, as well as the optimal format of such sessions, need
systematic study.
The review is hampered by lack of detail in the study design; some
aspects of study design are not clear, for example whether samples
were randomised. The small sample sizes and selection criteria are
likely to over estimate the results. The authors point to several
limitations in the studies reviewed; these include potential bias
when participants have a prior history of positive interaction with
animals, small sample sizes, and unclear duration of impact.
The second review, Cohen-Mansfield (2001) was rated as -. The
review appraised the impact of non-pharmacological interventions
on inappropriate behaviours in dementia and identified three AAT
studies. All three studies reported positive results (the interventions
are: certified dog therapy for two 30 minute sessions, companion
animals and a pet dog for one hour a day for five days). However, in
the latter study only 22% of participants had been diagnosed with
dementia. There is little quality assessment within the review in
respect of the type of study design (RCT, case study etc) which
means that all the studies included appear to be given equal weight.
Methodological issues are presented within the discussion section,
these relate to diverse measurement methods, criteria for success,
screening procedures, control procedures and treatment of failures.
Summary
The majority of studies in the reviews conformed to the definition of
AAT in as much as they included a trained animal (usually a dog)
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and trained handler rather than evaluating the impact of having a
pet per se.
The studies that explored use of AAT (typically the introduction of a
dog or cat at specified periods or a ‘resident’ dog) report positive
results in behaviour and psychological symptoms (reducing
agitation and aggression, improving social behaviours including
more interaction and longer duration of smiles). However, as noted
by Filan and Lllewellyn-Jones, the studies were characterised by
small sample numbers, include potential bias when participants
have a prior history of positive interaction with animals and duration
of any improvement is unclear. The lack of detail in reporting the
studies (even where it is clear there is a control group, it is unclear
whether participants have been randomly assigned to the groups)
means that the evidence is not robust.
The conclusion drawn is that AAT might work to reduce aggression
and agitation, improve social behaviour and improve nutrition.
However, further research that addresses the above limitations is
required in order to provide evidence that it does work.
Aromatherapy
Aromatherapy is the systematic use of essential oils in holistic
treatments with the aim to improve physical and emotional well-
being. It is reported that essential oils, extracted from plants, can be
utilised to improve health and prevent disease and are applied in a
variety of 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
16 http://www.aromatherapycouncil.co.uk/index_files/Page390.htm
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of aromatherapy in reducing behavioural and psychological
symptoms (agitation, neuropsychiatric symptoms and wandering). A
summary of the key characteristic of the reviews are provided in table 3,
p119-120.
Thorgrimsen et al (2003, 2006), in their review, rated ++, appraised
two randomised controlled trials. The first compared use of lemon
balm (Melissa) plus a base lotion against sunflower oil both applied
to the arms and face twice daily over four weeks. Additional
analyses of the study data revealed a statistically significant
treatment effect in favour of the aromatherapy intervention on
measures of agitation and neuropsychiatric symptoms, but there
were several methodological difficulties with the study. The second
trial in the review compared the effects of lavender applied through
massage, lavender applied through a diffuser accompanied by
conversation and conversation alone. No statistically significant
difference was found between groups.
Similarly Robinson et al (2006, 2007) in their review (again rated +
+) reported on two randomised controlled trials (the first is the
same lemon balm trial reviewed by Thorgrimsen et al, the second
compares lemon balm and lavender with neutral control oil). Overall
the review reported no robust evidence of the efficacy and the
evidence was deemed to be of low quality. The first randomised
controlled trial reported that participants receiving essential oils
showed less wandering behaviour (marginal statistical significance);
the second found no difference between groups.
Diamond et al (2003) (rated -) included seven aromatherapy studies
within their review. The review included both the randomised
controlled trials in Robinson et al. Diamond et al reported that
aromatherapy may have moderately beneficial effects; but that
better controlled studies with larger sample sizes are needed to
evaluate the effect of aromatherapy on the affect and behaviour of
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persons with dementia. The review was rated – because study
quality was not assessed within the review, all the studies included
were given equal weight.
Summary
There is some evidence that aromatherapy might reduce agitation,
neuropsychiatric symptoms and wandering. However, relatively few
studies were identified within the reviews and the evidence that was
presented was not robust. The randomised controlled trials within
the reviews produced conflicting results in terms of their
effectiveness. These conflicting results may be a result of
differences between interventions (for example, the oils use). All
reviews suggested that better controlled studies with larger sample
sizes are needed to evaluate the effect of aromatherapy.
Behaviour Management
Behaviour management covers a wide spectrum of techniques to
address challenging behaviour. Some of these are addressed in
separate sections within this review (for example environmental
manipulation to manage wandering)
Three studies were found that included behaviour management
studies (Robinson et al, 2006, 2007; Verkaik et al, 2005; Livingston
et al 2005). Of interest in the reviews was the effect on wandering,
depression, aggression, apathy and neuropsychiatric symptoms.
The interventions under the behaviour management umbrella
included social skills training, problem solving and behavioural
reinforcement. A summary of the key characteristic of the reviews
are provided in table 4, p121-122.
Robinson et al (2006, 2007) reviewed the clinical and cost
effectiveness and acceptability of non-pharmacological
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interventions to reduce wandering in those with dementia. The
review, rated ++, identified one study evaluating the effectiveness
of individualised behaviour management. This study, a non-
randomised control trial, did not provide evidence that the
intervention was effective in preventing/reducing wandering.
The second review (Verkaik et al, 2005; rated +) again included only
one behaviour management study, although this was not the same
study included in the Robinson review. The review assessed the
effect of psychosocial methods on depressed, aggressive and
apathetic behaviours of people with dementia; the study focussed
on the use of behaviour therapy for alleviating depression. Verkaik
et al concluded that there is limited evidence (one high quality
randomised controlled trial) that people with probable Alzheimer’s
disease living at home with depression are less depressed when
their caregivers are trained in using behaviour therapy-pleasant
events or behaviour therapy-problem solving rather than given
standard information from a therapist or no information/training.
The final review to include behaviour management interventions
(Livingston et al, 2005; rated +) explored psychological approaches
to the management of neuropsychiatric symptoms of dementia.
Twenty five papers in the review reported on non-dementia specific
psychological therapies for patients with dementia. Nearly all of the
studies examined behavioural management techniques. The studies
were judged to be of relatively low quality (rated 4 on a scale of 5
where a lower number indicates higher quality). The authors
reported that the findings of the larger randomised controlled trials
were consistent and positive, and the effects lasted for months.
However, perusal of the table of evidence provided in the review
does not appear to bear these conclusions out. Three randomised
controlled trials report conflicting results in respect of behavioural
changes; the first (n=89) reports no reduction in disruptive
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behaviour whilst the second (n=17) saw a significant reduction in
behavioural symptoms and the third (n=8) found reduced social
aggression. Similarly one randomised controlled trial (n=42) found
behavioural management techniques significantly reduced
depression whilst another (n=8) found no effect on depression.
Summary
The reviews have shown that behavioural management
interventions might work in alleviating some behavioural and
psychological symptoms of dementia. However evidence of their
effectiveness in respect of reducing wandering, depression,
aggression, apathy and neuropsychiatric symptoms is inconclusive.
Whilst a number of randomised controlled trials were identified they
were characterised by small sample numbers. Of the two
randomised controlled trials with larger sample sizes (n=89 and
n=72) only one reported a positive result (reduction in depression
scores). Well constructed and designed trials with larger sample
sizes are required.
As the reviews indicate carers may apply behaviour management
techniques. The techniques are usually structured, systematically
applied, time limited and, importantly, carried out under the
supervision of a professional with expertise in the 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).
17 http://www.sign.ac.uk/pdf/sign86.pdf
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Five reviews assessed evidence in this area (Clare & Woods, 2003;
Grandmaison & Simard, 2003; Sitzer et al, 2006; Bates et al 2004;
Livingston, 2005). Two were rated as ++ (Clare & Woods, 2003;
Sitzer et al, 2006) and three as +. Focus of the reviews was
improved memory and cognitive functioning, and management of
neuropsychiatric symptoms. A summary of the key characteristic of
the reviews are provided in table 5, p123-125.
Clare and Woods (2003) reviewed the evidence of the effectiveness
and impact of cognitive training and cognitive rehabilitation
interventions aimed at improving memory and other aspects of
cognitive functioning for people in the early stages of Alzheimer’s
disease or vascular dementia. The review included nine studies, all
randomised controlled trials. The interventions included cognitive
skills remediation training, memory training or coping programmes
and cognitive training. The authors reported no significant benefits
of cognitive training stating that the available evidence is limited;
there is no indication of any significant effects from cognitive
training. However, they suggested that the use of standardised
neuropsychological measures may result in positive effects on daily
living capabilities going unrecognised. Similarly, the review is
unable to draw any conclusion about the efficacy of individualised
cognitive rehabilitation interventions for people with early stage
dementia due to lack of randomised controlled trials.
The Sitzer et al (2006) review was rated as ++. The review
performed a meta–analysis in order to review the literature and
summarise the effect of cognitive training for Alzheimer’s disease.
The studies included under the cognitive training umbrella include a
diverse range of interventions (including reality orientation and
reminiscence therapy). The authors group the studies into either
compensatory strategies (that aim to teach new ways of performing
cognitive tasks by working around cognitive deficits) and restorative
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strategies (that aim to improve functioning in specific domains with
the ultimate goal of returning function in those domains to pre-
morbid levels). Using Cohen’s d, effect sizes were calculated for
each cognitive domain. The authors concluded from the analysis
that cognitive training evidenced promise in the treatment of
Alzheimer’s disease with primarily medium effect sizes for learning
memory, executive functioning, activities of daily living, general
cognitive problems, depression and self-rated general functioning.
Restorative strategies demonstrated the greatest effect on
functioning. They note however that the results are limited due to
the small number of well controlled studies, small sample numbers
and difficulties associated with outcome measures. Overall the
review was well presented with clear analysis. However, the
diversity of the interventions included mean that only broad
conclusions may be drawn. It is of interest that studies identified as
higher quality ‘painted a less optimistic picture of efficacy’.
A review of memory stimulation programmes (Grandmaison &
Simard, 2003), rated +, assessed evidence of the efficacy of
stimulation strategies or programmes in Alzheimer’s disease. The 17
studies included cover visual imagery, encoding specificity
strategies, errorless learning, external memory aids and dyadic
training. The review concluded that it is possible to stimulate
memory in Alzheimer’s disease. The errorless learning, spaced
retrieval, and vanishing clues techniques, together with the dyadic
approach seem to present the best training methods for patients
with Alzheimer’s disease but there is a need for more randomised
trials to validate the treatment approaches. The review itself was
comprehensive but inclusion of only two databases for the search
may have led to the exclusion of pertinent studies. As the authors
indicated, whilst the evidence suggests positive results the majority
of studies contain small sample numbers making identification of
statistically significant improvements difficult.
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Bates et al (2004), in their review rated +, investigated the
effectiveness of psychological interventions for people with milder
dementing illness. They included one memory stimulation study.
The study found no significant improvement in functional and
cognitive ability and thus the review did not find any evidence of the
effectiveness of procedural memory stimulation.
The final review (Livingston et al, 2005), rated +, explored the
management of neuropsychiatric symptoms. Livingston et al
assigned the evidence from the four papers a grade representing
mostly consistent evidence that cognitive stimulation therapy
improves aspects of neuropsychiatric symptoms immediately and
for some months afterwards. All four studies were randomised
controlled trials, three of the four showed positive improvements
(fewer behavioural problems but returning to baseline at nine month
follow up, significant decrease in depression, improvement in quality
of life). Overall the review is comprehensive but it is limited by lack
of detail. Two of the studies included in this review (Quayhagen et
al, 1995, 2000) are also included in the Clare & Wood review. Whilst
Livingston et al do not comment on the study design other than to
assign a grade representing ‘mostly consistent evidence’, Clare &
Wood point to methodological limitations including those relating to
randomisation, performance and attrition bias in both studies.
Summary
In line with the aims of cognitive stimulation therapy or training, the
studies within the review reflected all three main symptoms types
(behavioural and psychological symptoms, cognitive function and
ability to perform ADLs). The reviews point to potential benefits
from cognitive rehabilitation and training – that it might work for
improving memory, cognitive functioning, neuropsychiatric
symptoms, behaviour, depression, quality of life, learning, and
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activities of daily living. The evidence presented is inconclusive. The
studies included in the reviews were primarily of small sample size
and whilst a number of randomised controlled trials have been
carried out these appear to have methodological limitations. The
meta-analysis carried out by Sitzer et al (2006) produced
encouraging results reporting medium effect sizes for learning
memory, executive functioning, activities of daily living, general
cognitive problems, depression and self-rated general functioning.
However the interventions included in the analysis, under the
umbrella of cognitive training, were diverse. The review did not
point to the effectiveness of any one type of cognitive training.
Counselling
Bates et al (2004) included counselling interventions in their review
of psychosocial interventions for people with milder dementing
illness (see table 6, p126). The review, rated +, identified just one
randomised controlled trial. They reported that counselling provided
an opportunity for the client to vent their concerns and receive
validated information about their mental status. However, the
effectiveness of individual counselling sessions were not
demonstrated on the outcome measures used (addressing recall,
logical memory, and learning). The sample size of the study was
small (n=20).
Summary
There is no evidence that counselling works for improving cognitive
function (recall, logic memory or learning). However, this statement
should be tempered with the caveat that only one randomised
controlled trial was identified within the review and this had a small
sample size.
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Environmental Manipulation
Three reviews (Livingston, 2005; Cohen-Mansfield, 2001; Spira &
Edelstein, 2006); considered studies that manipulated the
environment to effect changes in neuropsychiatric symptoms and
inappropriate behaviours including agitation. A summary of the key
characteristic of the reviews are provided in table 7, p127-128.
A review of psychological approaches to the management of
neuropsychiatric symptoms of dementia (Livingston, 2005; rated +)
identified 19 studies using some form of environmental
manipulation. The studies within the review addressed a multitude
of different behavioural challenges including wandering, aggression
and agitation. Eight studies within the review investigated the
effects of changing the visual environment; the authors assessed
that there was consistent evidence from lower grade studies for
changing the environment to obscure the exit (to reduce
wandering). Two studies that investigated the use of mirrors found
inconclusive/inconsistent evidence (in reduction of agitation and
wandering). Similarly the evidence from three studies that
investigated use of signposting was judged
inconclusive/inconsistent.
Cohen-Mansfield (2001; rated -) reviewed the impact of non-
pharmacological interventions on inappropriate behaviours. Of the
six ‘environment’ studies identified two studies showed free access
to an outdoor area resulted in decreased agitation; two found a
simulated natural environment decreased agitated behaviours; and
two report reduced agitation after initiation of a reduced stimulation
environment. All the studies have small sample number and little
account is taken of study design by the review.
The Spira & Edelstein review (2006; rated -) of behavioural
interventions to reduce agitation in older adults with dementia
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identified six ‘environment’ studies. In respect of wandering and
hazardous behaviour the authors report that taken together the six
studies show the intervention can have clinically meaningful effects
on wandering in older adults with dementia; but contradictory
results were obtained concerning the utility of particular stimuli.
Only one study, a single subject case study assessed disruptive
vocalization. The review is limited in as much as only one database
was searched which is likely to have limited papers identified.
Unfortunately the prevalence of single subject and case study
designs together with the majority of studies measuring the
occurrence of target behaviours by direct observation means this
evidence is at best weak and likely to over estimate the results.
Summary
The interventions included in this category were diverse; they
included the use of mirrors, sign-posting and access to outdoor
areas. The studies were characterised by small sample sizes and
were typically of low quality. Indeed even between similar
interventions the results were generally conflicting. The absence of
robust studies (in particular randomised controlled studies) meant it
was only possible to conclude that environmental manipulation
might work for improving behavioural and psychological symptoms,
specifically neuropsychiatric symptoms, agitation and wandering.
Further evidence of effectiveness is needed.
The studies included in the review were based in residential or
institutional settings and as such may not be easily transferable to a
home setting. However, access to an outside area such as a garden
(rather than being confined indoors) may be useful in deceasing
agitation or aggression.
Light Therapy
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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.
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.
18 http://www.columbia.edu/~mt12/blt.htm
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vascular dementia) which have been insufficiently tested. Whilst
the Skjerve et al review is comprehensive, the process of study
selection, extraction and synthesis are not presented.
Kim et al (2003) evaluated the effects of bright light therapy on the
sleep and behaviour of dementia patients. From the 14 studies
assessed they found evidence for effectiveness inconclusive; that
there is a need for controlled studies to look at the relationship
between dementia, agitation, sleep-wakefulness and bright light in
community or nursing home populations. Assessment of the review
(rated -) was constrained by lack of details pertaining to the
literature search and the wide inclusion criteria which could
overestimate effects.
Similarly Cohen-Mansfield (2001), in a review of the impact of non-
pharmacological interventions on inappropriate behaviour, report
that the results in the seven papers identified were inconclusive,
some studies showed a significant decrease whilst others reported a
trend. The authors suggested that these differences may stem from
differences in design and measurement or from differences in
population. The volume of studies included in the overall review
(n=83) mean that some, but not all of the studies are described, but
all are given equal weight. The review was rated -.
Summary
The four reviews agreed that the evidence for the use of light
therapy was inconclusive; that light therapy might work when used
to improve behavioural and psychological symptoms (sleep,
behaviour, mood, agitation) and cognition . Whilst research has
reported positive effects, the studies have been of poor quality; in
particular well designed randomised controlled trials are needed. In
addition, as indicated by Skjerve et al, whilst the majority of studies
included in the reviews used some form of bright light lamp, the
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different effects may be due to differences in treatment (brightness,
duration, timing) or condition (e.g. vascular dementia) which have
been insufficiently tested.
Massage/Touch Therapies
Three reviews appraised the use of massage or touch therapies
(Viggio Hansen et al, 2006; Livingston et al, 2005; Cohen-Mansfield,
2001). Of interest are behavioural and psychological symptoms
(nutrition, agitation, wandering, anxiety and aggression). A
summary of the key characteristic of the reviews are provided in
table 9, p132-133.
Viggio Hansen et al (2006) assessed the effectiveness of massage
and touch therapies offered to patients with dementia (rated ++).
Only two randomised controlled trials were included in their review.
The interventions are gentle touch on the forearm accompanying
encouragement to eat and hand massage (and calming music with
hand massage). The former study reported a significant increase in
mean intake of calories as well as protein in the group receiving
verbal encouragement and touch (but no change in control). The
latter study found a decrease in agitated behaviour greater in the
group receiving hand massage than that in usual care. The review
concluded that some evidence is available to support the efficacy of
two specific applications: the use of hand massage for an immediate
and short term reduction in agitated behaviour, and the addition of
touch to verbal encouragement to eat for the normalization of
nutritional intake.
A second review, Livingston et al (2005) rated +, reviewed
psychological approaches to the management of neuropsychiatric
symptoms of dementia. The authors identified three studies in this
area only one of which is a randomised controlled study. The
authors reported no evidence for sustained usefulness. However,
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the randomised controlled trial (the same study as reported by
Viggio Hansen et al) that compares calming music, hand massage,
music followed by massage or music and massage simultaneously
for 10 minutes each, finds all groups had reduced agitation relative
to usual care. The effect lasted one hour.
The final review (Cohen-Mansfield, 2001), assessed as -, identified
six studies that evaluated massage or touch therapies. The aims of
the studies included one or more of the following: reduced
wandering, agitation/anxiety and aggressiveness. Four appraised
hand massage, one back massage; one is merely described as slow
stroke massage. One study reported unequivocal success, the
others either a positive trend, partial effects (physical and verbal
behaviours) or no effect (aggression). The study designs were not
clear. The large number of studies included in the overall review
mean that some, but not all of the studies are described, but all are
given equal weight.
Summary
There is evidence to suggest massage or touch therapies work in a
number of areas. The evidence suggests:
Hand massage; music followed by hand massage or music and
massage simultaneously each for 10 minutes can have an
immediate effect and short term reduction in agitated behaviour
Gentle touch on the forearm accompanying verbal
encouragement can increase mean intake of calories
However, there is no conclusive evidence that massage reduces
wandering, anxiety or aggressiveness.
Music / Music Therapy
Music and music therapy has been advocated as offering possible
beneficial effects on symptoms of dementia including social,
emotional and cognitive skills and for decreasing behavioural
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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, 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
19 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=90&pageNumber=120 http://www.bsmt.org/what_is_mt.htm21 http://www.bsmt.org/what_is_mt.htm
Charles Thackrah BuildingUniversity of Leeds101 Clarendon RoadLeeds, United KingdomLS2 9LJ
www.leeds.ac.uk/lihs
with those with dementia. The reviews were of mixed quality, four
were assessed to be ++, three + and three -. With the exception of
Vink et al (2003) study design was not restricted to randomised
controlled trials.
The Vink et al (2003) review, rated ++, assessed the efficacy of
music therapy in the treatment of behavioural, social, cognitive and
emotional problems of older people with dementia. Five studies
were included in the review; all were randomised controlled trials.
Three compared music listening with a control intervention or no
intervention. The interventions included playing a patient’s
preferred music compared with classical music to reduce agitation;
playing preferred music during bath time to reduce occurrences of
aggressive behaviour; and group music activities including listening,
singing and playing compared with group reading sessions in
reducing wandering behaviour. All reported music listening more
effective than the control or no control. A further study compared
music group therapy with conversation sessions and music therapy
(intervention appears to be based primarily on singing) and the
affect on language functioning. It reported music therapy to be
more effective. The final study compared music therapy with puzzle
activities and general activities and again was reported to be more
effective in improving social and emotional functioning. However,
Vink et al assessed that none of the studies presented any of the
quantitative results in sufficient detail to justify the conclusions
drawn.
Sung and Chang (2005) provided a summary of the effects of
preferred music on agitated behaviours for older people with
dementia. The review included eight studies (two of which were
included in the Vink et al review). Whilst these two were randomised
Charles Thackrah BuildingUniversity of Leeds101 Clarendon RoadLeeds, United KingdomLS2 9LJ
www.leeds.ac.uk/lihs
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.
Charles Thackrah BuildingUniversity of Leeds101 Clarendon RoadLeeds, United KingdomLS2 9LJ
www.leeds.ac.uk/lihs
Lou (2001) reviewed interventions that use music to decrease
agitated behaviour of the demented elderly person. All papers
identified for the review were included in one or more of the reviews
above. The interventions were all music listening (albeit some
described as background music). Lou concluded that music can be
useful as an intervention to help patients deal with agitated
behaviour problems and can increase patients’ quality of life but
that weakness and limitations in study design are considerable. The
review was rated -, because the search strategy is not clear in as
much as inclusion criteria is preferably with demented elderly and
no details are given of the numbers of papers identified in initial
screening. Limiting the search to two databases may have reduced
the papers identified.
The final review whose focus was solely music and music therapy,
Nugent (2002), examined the use of music and music therapy for
people who have Alzheimer’s disease and related disorders (ADRDs)
and display agitated behaviours. The review, rated -, supported the
premise that music and music therapy interventions reduce the
occurrence and frequency of agitated behaviours, that music
therapy may prevent extreme forms of agitation and that the
studies demonstrate that wandering and general restlessness is
reduced significantly. However, the author acknowledged that more
rigorous designs that include refined measuring tools and studies
that have larger sample sizes are required to gather more data. The
author’s conclusions were likely to overstate the effectiveness of the
interventions as all studies were given equal weight irrespective of
study quality and there is insufficient detail or assessment of the
quality of the papers.
Robinson et al (2006, 2007), rated ++, included one music therapy
study in their review of the clinical and cost effectiveness and
acceptability of non-pharmacological interventions to reduce
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47
wandering in dementia. The study (Groene, 1993) was included in
two of the previous reviews (Vink et al and Sherratt et al). Robinson
et al concluded that there is no evidence for the effectiveness of
music therapy and that the identified evidence was assessed to be
of low quality. This concurred with the conclusion made by Vink et
al.
Similarly, Warner et al (2006), in their review of the effects of
treatment on cognitive symptoms of dementia and the effects of
treatments on behavioural and psychological symptoms of
dementia, concluded that music therapy has unknown effectiveness.
Their review, rated ++, identified two reviews and one subsequent
randomised controlled trial. However, the conclusions are in part
based on the evidence found in Vink et al review described
previously (which is one of the reviews included here). The
randomised controlled trial identified found that music based
exercise improved cognition after three months compared with one
to one conversation with a therapist but Warner et al pointed to
methodological deficiencies in the trial including the possibility of
allocation and assessment bias.
Watson and Green (2006) reviewed evidence for interventions to
assist older people with dementia to feed. The review, rated +,
identified four papers that included music. The intervention in all
four studies was playing music at lunchtime. The authors report that
all studies showed improvements in the outcomes measured but
that statistical significance was seldom reported. However the
results précis provided by Watson and Green showed only two
studies that report changes in feeding, food intake or food helpings;
and these appear inconclusive. Within the review the quality
assessment criteria is not clear and the search terms are likely to
have limited identification of relevant studies.
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Another general review (Livingston et al, 2005; rated +) of
psychological approaches to the management of neuropsychiatric
symptoms of dementia identified 24 music or music therapy studies.
The authors suggested that the studies show consistent evidence
that music therapy decreases agitation during sessions and
immediately after but that there is no evidence that music therapy
is useful for treatment of neuropsychiatric symptoms in the longer
term. Whilst overall it is a comprehensive review, it is let down by
lack of detail in search strategy which means it is not replicable. In
addition, due to the very large number of papers included in the
review (162), other than highlighting the randomised controlled
trials, it is difficult to determine study design or details such as
sample characteristics or setting.
Similarly a further general review (Cohen-Mansfield, 2001, rated -)
that considered the impact of non-pharmacological interventions on
inappropriate behaviours in dementia reported that all but one of
the 11 studies identified reports either a significant reduction or
positive trend in some inappropriate behaviours. The volume of
studies included in the overall review (n=83) mean that some, but
not all of the studies were described, but all were given equal
weight. Whilst methodological issues were presented within the
discussion section, these relate to diverse measurement methods,
criteria for success, screening procedures, control procedures and
treatment of failures; little or no account is taken of study design.
Summary
The papers that explored the use of music and music therapy
formed the largest grouping within this review. The evidence
presented leads to the conclusion that music and music therapy
does work in reducing a number of behavioural and psychological
symptoms problems. These include reducing agitation, aggression,
wandering and restlessness, irritability and social and emotional
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difficulties and improving nutritional intake. However despite the
large number of studies, the reviews did identify some
methodological limitations (including weak study designs and small
sample numbers) which mean that the evidence is not strong.
The evidence suggests the following:
Playing preferred (favourite) music may reduce agitation
Playing preferred music during bath time may reduce
occurrences of aggressive behaviour
Group music activities including listening, singing and playing
compared may reduce wandering behaviour.
Physical Activity/Exercise
The beneficial effects of a physically active lifestyle in health
promotion are well-documented (DH, 2004; WHO, 2004). Five
systematic reviews evaluated the evidence of the effect of physical
activity/exercise on mood, sleep, functional ability (activities of daily
living), wandering, agitation and cognitive function for those with
dementia (Eggermont & Scherder, 2006; Robinson et al, 2006,
2007; Livingston et al, 2005; Penrose, 2005; Cohen-Mansfield,
2001). The quality of the reviews varied from ++ rating to - rating.
A summary of the key characteristic of the reviews are provided in
table 11, p140-143. Hermans et al 2007, in their review of non-
pharmacological interventions for wandering of people with
dementia, also highlight the use of exercise and walking therapies
that aim to prevent and/or reduce wandering but were unable to
identify any studies in this area that fitted the review inclusion
criteria.
Eggermont & Scherder (2006), rated ++, evaluated the effect of
planned physical activity programmes on mood, sleep and
functional activity in people with dementia. The review included 27
studies, six of which were randomised controlled trials. The
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randomised controlled trials included a daily seated exercise
programme, exercise to music three times a week and daily 30
minute walks. Eggermont and Scherder found, taking the
methodological quality of the studies and differences between
interventions into consideration, that sustained walking in particular,
may benefit affective behaviour (mood) and that physical activity
appears to have a beneficial impact on the quality of sleep.
Based on their evaluation of the evidence they suggested that:
Exercise programmes should include a walking activity and
take at least 30 minutes in order to benefit mood;
Exercise should be offered frequently during the week
irrespective of duration, to achieve a positive impact on sleep;
Care home residents need a long-term exercise programme
with extensive sessions if a positive impact on their ADL is to be
achieved (Eggermont & Scherder, 2006; p418).
Robinson et al (2006, 2007) in their review, again rated as ++,
attempt to determine the effectiveness and acceptability of non-
pharmacological interventions to reduce wandering dementia. The
review identified one randomised controlled trial that compared a
moderate intensity exercise programme (aerobic/endurance
activities, strength training, balance and flexibility training) with
usual care. The setting was an Alzheimer’s unit in Italy. The
reviewers concluded that the study provided some evidence that
moderate intensive exercise may reduce wandering.
Two of the remaining reviews cited inconclusive evidence.
Livingston et al (2005), rated +, considered the effect of
psychological approaches on neuropsychiatric symptoms. Two of
the four studies identified in this review were randomised controlled
trials that evaluated a walking/talking programme and a
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psychomotor activation programme respectively. Neither reported
significant behavioural changes.
Penrose (2005), rated -, appraised the role of exercise, including
aerobic and resistance training, in maintaining or improving the
cognitive function of persons with Alzheimer’s disease. The review
concluded that there was a lack of strong evidence of statistical
significance to prescribe exercise/physical activity to maintain
cognitive function or prevent cognitive decline in persons with
Alzheimer’s disease. However, many of the studies reported within
the review did not reflect the review question and it was unclear
how many studies were included. The two randomised controlled
trials reported both had small sample numbers (it is not clear
whether more randomised controlled trials were identified).
The final review that included evidence of the impact of physical
activity was Cohen-Mansfield (2001) and was assessed to be rated -.
The review explores the impact of non-pharmacological
interventions on inappropriate behaviours. Two studies within the
review focussed on outdoor walks; the intervention for the first
involved escorting residents to an outdoor garden (a one to one
intervention); the second consisted of group walks through common
areas or outside. The review reported decreases in inappropriate
behaviour for both interventions (the former found a significant
decrease in physically aggressive behaviours and non-aggressive
behaviours; the latter a significant decrease in agitation). It is
doubtful that the findings were statistically significant given the
small sample numbers (n=12 and n=11 respectively). Two more
physical activity studies were included in the review table, but the
author made no comment with regard to their results.
Summary
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The evidence suggests that physical exercise does work for
behavioural and psychological symptoms and functional ability;
evidence from the reviews was consistent with Eggermont and
Scherder (2006):
Sustained walking may benefit mood
Physical activity appears to have a beneficial impact on the
quality of sleep
Whilst physical activity may have positive effects on functional
ability in care home residents this is only when a long lasting
exercise programme is applied
Moderate intensive exercise may reduce wandering
Reality Orientation
Reality orientation aims to decrease confusion and dysfunctional
behaviour patterns in people with dementia by orientating patients
to time, place and person (Paton, 2006). Three reviews (Bates et al,
2004; Livingston et al, 2005; Verkaik et al, 2005), all rated +,
included reality orientation studies in their paper. A summary of the
key characteristic of the reviews are provided in table 12, p144.
Bates et al (2004), in their review, investigated the effectiveness of
psychological interventions for people with milder dementia. Two
studies were identified and the authors concluded that, taking the
two studies together, there is evidence that reality orientation is an
effective intervention in improving cognitive ability. However,
neither study demonstrated that reality orientation is effective in
improving well-being or improving communication, functional
performance and cognitive ability. It is of note that the studies had
small sample sizes and no power calculations which could overstate
positive results.
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Livingston et al (2005) explored psychological approaches to the
management of neuropsychiatric symptoms of dementia. Their
review identified 11 reality orientation studies and reported
inconclusive evidence. Of the two randomised controlled included,
one showed no immediate benefit compared with active ward
orientation; whilst the other showed a non-significant improvement
in behaviour when reminiscence therapy was preceded by reality
orientation but not vice versa.
The effect of psychosocial methods on depressed, aggressive and
apathetic behaviours of people with dementia was reviewed in
Verkaik et al (2005). The review identified five studies, two
randomised controlled trials and three case control studies. The
quality of all five studies was assessed to be low. Only one study
found significant improvement in depression; one further study
reported improvement in apathy. The authors concluded that there
were no or insufficient indications that the intervention reduces
depressive, aggressive or apathetic behaviours in people with
dementia.
Summary
Reality orientation might work but the evidence presented is
inconclusive. The quality of the studies included in the reviews is, as
acknowledged by the review authors, low. Again the studies were
characterised by small sample numbers. Whilst there are positive
results reported in respect of improvements in cognitive ability,
depression and apathy the reviews agree that the evidence is
inconclusive.
Reminiscence Therapy
Reminiscence therapy involves the discussion of past activities,
events and experiences with another person or group of people,
usually with the aid of tangible prompts such as photographs,
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household and other familiar items from the past, music and archive
sound recordings (Woods et al, 2005, p1). Four reviews assessed
reminiscence therapy studies in respect of cognitive symptoms,
mood, behavioural and psychological symptoms, management of
neuropsychiatric symptoms and depressed, aggressive and
apathetic behaviours in people with dementia (Warner et al, 2006;
Woods et al, 2005; Livingston et al, 2005; Verkaik et al, 2005). Key
characteristics of the reviews are outlined in table 13, p145-146.
Warner et al (2006), in a review rated ++, explored the effects of
treatment on cognitive behavioural and psychological symptoms of
dementia. Within the review three studies are identified that
assessed reminiscence therapy. These included one systematic
review (Woods et al, 2005, discussed further below) that performed
a meta-analysis and found reminiscence therapy improved
cognition. The studies included in the analysis used diverse
measures and were often small. Warner et al recommended that
larger and better studies on reminiscence therapy are needed.
The Woods et al (2005) review was itself rated ++. Five randomised
controlled trials were included in the review but data was extracted
for only four of those studies for the meta-analysis. The inclusion
criteria were such that the trials included could be either group or
individual sessions involving photographs, music and videos of the
past. The duration was set at a minimum of 4 weeks and 6 sessions
and led by professional staff or by care-workers trained by
professional staff. The interventions were either on an individual or
group basis and the format of the sessions was diverse. For
example, reminiscence facilitated by old photographs, books,
magazines, newspapers and domestic articles or, in another study,
by the development of a life story book.
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The authors reported results of the analysis that were statistically
significant for cognition (at follow-up), mood (at follow-up), and on a
measure of general behavioural function (at end of intervention
period). Improvement in cognition was evident in comparison with
both no treatment and social contact conditions. However, of the
four randomised controlled trials included, several were very small
studies, or were of relatively low quality and, as indicated above,
each examined different types of reminiscence work. They
concluded that more and better designed trials are needed so more
robust conclusions may be drawn.
Livingston et al (2005), in their review of psychological approaches
to the management of neuropsychiatric symptoms of dementia,
identified five reminiscence therapy studies. The review assigned a
grade to the studies equivalent to troublingly inconsistent or
inconclusive studies. Of the three randomised controlled trials
included one found a non-significant improvement when
reminiscence therapy was preceded by reality orientation but not
vice versa; the other found no benefit. The review itself was rated as
+, whilst being comprehensive it was let down by lack of detail in
the search strategy which means it is not replicable. In addition, due
to the very large number of papers included in the review (n=162),
other than highlighting the randomised controlled trials it was
difficult to determine study design or details such as sample
characteristics or setting.
Another review rated as + (Verkaik et al, 2005) identified two
reminiscence therapy studies within its review of the effect of
psychosocial methods on depressed, aggressive and apathetic
behaviours of people with dementia. One randomised controlled trial
judged to be of low quality reported significantly lower self-reported
depression at post-test. Whilst a case control study reports no
changes in apathy.
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Summary
In line with Woods et al, the reviews showed evidence that
reminiscence therapy might work; that it has potential benefits in
terms of cognition, mood and general behaviour. However these
results are based on trials with small sample sizes and of relatively
low quality. In addition there was variation in the type of
reminiscence work reported. Thus whilst there is the potential for
reminiscence therapy to be beneficial in all these areas evidence of
their effectiveness is not robust. The study limitations highlighted by
Woods et al need to be addressed.
Snoezelen/Multi-sensory Stimulation
Multi-sensory stimulation (MSS), also known as Snoezelen, is visual,
auditory, tactile and olfactory stimulation offered to people in a
specially designed room or environment (Baker et al, 2001). Six
reviews explored the use of MSS in people with dementia. MSS was
the sole focus of two reviews (Chung & Lai, 2002; Lancioni et al,
2002) whilst the remainder identified MSS studies in more general
reviews (Robinson et al, 2006, 2007; Livingston et al, 2005; Verkaik
et al 2005; Cohen-Mansfield, 2001). The effects on disruptive
behaviour, mood, depression, aggression, apathy, cognition,
social/emotional behaviours, wandering and neuropsychiatric
symptoms were assessed. A summary of the key characteristic of
the reviews are provided in table 14, p148-149.
Chung and Lai (2002), rated ++, assessed the efficacy of Snoezelen
as a therapeutic intervention for older people with dementia.
Including only randomised controlled trials the review identified
three papers representing two trials. The first (Baker et al, 2001)
compared Snoezelen to a one to one programme based on
individuals’ preferences and abilities with no provision of obvious
sensory inputs. The second was an extension of the first trial (Baker
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et al, 2003). The third paper, van Weert (2005) reported on the
effect of Snoezelen on mood, behaviour and communication. The
review combined the data from the latter two papers and found, in
respect of behaviour, the results favoured the Snoezelen
programme but there were no longer term treatment effects; no
significant effects on mood were reported post intervention and no
longer term effects on communication/interaction. Thus overall the
review found no evidence for efficacy of Snoezelen for dementia.
The review suggested there is a need for more reliable and sound
research-based evidence to inform and justify the use of Snoezelen
in dementia care.
Lancioni et al (2002) examined within-session, post-session and
longer-term effects of Snoezelen with people with developmental
disabilities and dementia. Whilst they identified 21 studies in the
review, only seven related to dementia; none of those identified
were included in the previous review (Chung & Lai, 2002). The
review authors’ tentative conclusions
were that Snoezelen may have positive within-session effects on
social/emotional behaviours. They went on to add that such positive
effects could be increased by choosing appropriate stimuli for
individual participants; and that increasing within-session positive
effects may increase post-session effects. However, the review was
only rated – for a number of reasons. The literature search was
limited; only PSYCLIT and Medical Express databases are included in
the computerised search and no details were given of the search
terms used, numbers of papers initially retrieved,
inclusion/exclusion criteria, or process followed. In addition there
was only limited discussion of study methodologies; this was
divorced from the results and did not provide strong guidance on
the interpretation of results from individual studies. Overall the
limitations may have resulted in effects being overstated.
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Robinson et al (2006, 2007) in their general review that aims to
determine the clinical and cost effectiveness and acceptability of
non-pharmacological interventions to reduce wandering dementia,
identified three MSS studies. All studies were randomised controlled
trials. Baker et al (1998) compared Snoezelen to a one-to-one non-
multi-sensory programme; Baker et al 2003 (described previously);
and McNamara & Kempenaar (2001) who compared MSS with tactile
stimulation. The review authors reported some evidence, albeit of
poor quality, for the effectiveness of multi-sensory environment. Of
the three randomised controlled trials; two did not provide evidence
that a multi-sensory environment effectively prevents wandering;
the third provided no follow up details and so the study yielded no
information about effectiveness. The review was rated ++.
Another more general review, Livingston et al (2005), rated +,
assessed psychological approaches to the management of
neuropsychiatric symptoms. From the six papers identified in the
review, the authors concluded that there was consistent evidence
from non-randomised controlled trials that the effects from MSS are
apparent for only a very short time after the session. Of the three
randomised controlled trials one had no clear results; two found
disruptive behaviour briefly improved outside the treatment setting
but there was no effect after the treatment stopped. Overall the
review was comprehensive but is let down by lack of detail in the
search strategy which means it is not replicable. In addition, due to
the very large number of papers included in the review (n=162),
other than the randomised controlled trials, it was difficult to
determine study design or details such as sample characteristics or
setting of the studies reviewed.
Verkaik et al (2005) explored the effect of psychosocial methods on
depressed, aggressive and apathetic behaviours of people with
dementia. Within the three studies identified they concluded that
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there is some evidence (from two high quality randomised
controlled trials) that MSS reduces apathy in people in the latter
stages of dementia. Overall the review is rated + primarily because
there was no discussion of the strength of evidence for no effect /
negative effect; only positive effect.
The final review in this section is, again a more general review.
Cohen-Mansfield (2001) carried out a review on the impact of non-
pharmacological interventions on inappropriate behaviours. Of the
four studies included the authors concluded that most report
improvement though it is not necessarily statistically significant. The
rating of – reflects that little or no account was taken of study
design within assessment of the studies.
Summary
The evidence showed that MSS might work. The reviews reported
positive results across a range of behaviours, including a reduction
in apathy in people in the latter stages of dementia from two
randomised controlled trials. Many of the improvements reported
were not statistically significant and some results were conflicting.
Overall the beneficial effects were not sustained and the reviews
agreed that evidence was not robust due to small sample sizes and
diverse measures of effectiveness.
Transcutaneous Electrical Nerve Stimulation (TENS)
One review, Cameron et al (2003) (rated as ++, see table 15, p150),
sought to determine the effectiveness and safety of TENS (the
application of an electric current through electrodes attached to the
skin) in the treatment of dementia. Whilst TENS is typically used in
pain relief, the review is based on studies by two groups (one in the
Netherlands and one in Japan) that suggest TENS, applied to the
back or head, may improve cognition and behaviour in those with
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dementia. Nine randomised controlled trials from the two groups
were included in the review and three of those in the meta-analysis.
The authors reported that TENS produced a statistically significant
improvement directly after treatment in delayed recall in one trial,
face recognition in two trials and motivation in one trial. There was
no effect on the other neuropsychological and behaviour measures
either directly after or 6 weeks after treatment. They concluded that
TENS may produce short term improvements in some
neuropsychological or behavioural aspects of dementia. However,
the limited presentation and availability of data from these studies
does not allow definite conclusions on possible benefits. In respect
of safety, although unlikely to have adverse effects, there is
insufficient data to recommend its use.
Overall the review is both comprehensive and well designed. As the
authors noted the studies included demonstrated consistency in
experimental designs, subjects, interventions and outcome
measures; but as only three could be used in the meta-analysis,
generalisability of the findings to a wider population requires the
work be replicated in a larger group of individuals.
Summary
The review shows that TENS might work but concludes that there is
insufficient evidence to recommend its use. The current evidence,
taken from randomised controlled studies within the review, shows
potential benefits in the short term (directly after treatment) in
recall, face recognition and motivation. Whilst the reviewed trials
were well constructed there was insufficient data for the meta-
analysis to, as noted by the authors, draw strong conclusions or to
recommend its clinical use for those with dementia.
Validation Therapy
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Validation is a method of communicating with and helping
disoriented very old people built on an empathetic attitude and a
holistic view of individuals22. The techniques of validation are simple
to learn and can be performed within the course of a typical day23.
Three reviews were identified that included assessments of
validation therapy with people with dementia (Neal et al, 2003;
Livingston et al, 2005; Verkaik et al, 2005). The reviews addressed
management of neuropsychiatric symptoms, cognition, emotion,
functional ability and depressed, aggressive and apathetic
behaviours. A summary of the key characteristic of the reviews are
provided in table 16, p151-152.
A review by Neal et al (2003), rated ++, assessed the efficacy of
validation therapy, offered in group or individual format, as an
intervention for patients with dementia or cognitive impairment.
Three studies that met the review criteria and were assessed. All
were randomised controlled trials. The first compared validation
therapy, reality orientation and usual care (Peoples, 1982); the
second validation therapy and usual care (Robb et al, 1986); and the
last validation therapy, social care and usual care (Toseland et al,
1997). The results from the three studies were presented in terms of
behaviour (two studies showed no statistically significant
improvements in treatment effects, one study showed significant
effect at 6 weeks); cognition (no statistically significant differences
were reported); emotional state (no significant differences reported
with the exception of depression at 12 months in one 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.
22 http://www.vfvalidation.org/whatis.html23 http://academic.evergreen.edu/curricular/hhd2000/Mukti's%20Notes/VALIDATION%20THERAPY.htm
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A systematic review of psychological approaches to the
management of neuropsychiatric symptoms of dementia (Livingston
et al, 2005; rated +) assessed three validation therapy studies and
concluded that there was no conclusive evidence. In this review
there was only one randomised controlled trial (Toseland et al, 1997
included in previous review) comparing validation therapy to usual
care or a social contact group. Toseland et al reported that no
difference was found in independent outcome ratings, nursing time
needed or in use of psychotropic medication and restraint.
The final review (Verkaik et al, 2005; rated +) considered the effect
of psychosocial methods on depressed, aggressive and apathetic
behaviours of people with dementia. This review included four
validation therapy studies, two randomised controlled trials (again
Toseland et al, 1997 was included) and two case control studies.
Like the other reviews, the authors concluded that there was no or
insufficient evidence; three studies found no significant changes in
apathy, aggression or depression. The Toseland study, as reported
previously, found significant change in depression after 1 year
compared with alternate therapy but not the usual care group.
Summary
Whilst the evidence shows that validation therapy might work there
is insufficient evidence that demonstrates the benefits of validation
therapy. Potential benefits assessed in the reviews included the
management of neuropsychiatric symptoms, cognition, emotion,
functional ability, depression, aggression and apathy; but few
studies reported improvements in any of these areas. The strength
of evidence is, in part, hampered because there are few randomised
controlled trials. Those trials that have been conducted are reported
to have methodological issues that include lack of clarity in
diagnosis of dementia, selection of outcome measures and the need
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for clarification about the precise nature of the intervention (Neal et
al, 2003).
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SECTION THREE
Introduction
The review in Section Two presented evidence of the effectiveness
of non-drug interventions in alleviating the symptoms of people with
dementia with the ultimate aim of helping people caring for
individuals with dementia who want ideas about non-drug
approaches for dementia that they might try or might access locally.
The review found evidence that a range of interventions either do or
might work to prevent or help cope with difficult behaviours or
symptoms. This section of the report integrates these findings with
suggestions and strategies identified from the website of four
national/international dementia organisations to explore how some
of the interventions identified in the review may be accessed or how
they may be used or adapted for carers to try at home. In addition,
where guidelines or recommendations have been made by the
National Institute for Health and Clinical Excellence (NICE) and the
Scottish Collegiate Guidelines Network (SIGN) these are presented.
The matrices on pages 154-56 show the suggested strategies or
interventions by dementia organisation, intervention type and
behaviour/symptom. It is important to note that the majority of
studies in the papers reviewed in Section Two related to dementia in
a generic sense, rather than to one specific type of dementia and as
such the recommendations made apply across all types of
dementia.
The section is presented in two parts. The first presents strategies
that carers might try by intervention type; the second by the
behaviour or symptom it may be used to help prevent or cope with.
In line with the evidence in review the strategies presented attempt
to address common behaviours and symptoms that people with
dementia may present: aggression, agitation, anxiety, wandering,
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hallucinations, sleeplessness and depression. The root of many of
these behaviours lies in confusion or frustration and the premise
behind many of the suggestions included is to provide structure,
stimulation (both mental and physical) and a calm environment to
help prevent behavioural difficulties. Of the strategies outlined to
help cope with difficult behaviours (behaviour and psychological
symptoms of dementia) many are activities that provide a method
of distraction from that behaviour. It is important to note that the
suggested strategies are unlikely to work for everyone, nor is any
one solution definitive – what works today may not work tomorrow24.
In addition advice should always be sought from a doctor given that
any changes in behaviour or symptoms may result from a physical
illness, discomfort or psychiatric illness25.
Interventions
Acupuncture
Acupuncture has been used to treat a number of conditions
including musculoskeletal pain, headaches, muscles strain, arthritic
pain, bowel problems, allergies, skin problems and in the
management of withdrawal from addictive substances. The process
involves fine needles being inserted through the skin and briefly left
in position. The number of needles varies but may be only two or
three26. Whilst acupuncture is one of the most popular forms of
complementary therapies in the UK (Smallwood, 2005), no evidence
was found to support its use for individuals with dementia and no
recommendations were made for its use on the dementia
organisations’ websites. If carers would like to explore the use of
acupuncture accredited practitioners may be identified through one
of the professional bodies in the field such as The British Medical
Acupuncture Society (http://www.medical-acupuncture.co.uk/) or
24 www.alzheimer-europe.org/pages/print_article.php?idart=8E3C2105BDFD25 http://www.alzheimers.org.au/content.cfm?infopageid=4025#why26 http://www.medical-acupuncture.co.uk/patients/
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The British Complementary Medicine Association
(http://www.bcma.co.uk/).
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.
27 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define128 http://www.nice.org.uk/nicemedia/pdf/CG042NICEGuideline.pdf29 http://www.alzheimers.org.uk/downloads/Dementia_SH_comments_formAlzSoc.pdf
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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 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.
30 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
31 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp
32 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1
33 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp
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A calm unstressed environment can help avoid behaviours
such aggression and agitation. Stroking a pet or petting for
example, a cat or dog can have a calming and relaxing effect;
similarly the presence of a fish tank may have a calming effect 34
Distraction is often useful when a person becomes agitated or
aggressive. An activity such as stroking or grooming a pet can
provide that distraction35
When becoming confused, restless or insecure the person with
dementia may be comforted by the presence of a pet36
To stimulate conversation try stroking or grooming the pet
together.
Walking the dog together can provide exercise for both the
person being cared for and the caregiver. Increased exercise can
reduce the risk of depression. It can also provide an opportunity for
enjoyment, pleasure and social contact37.
Aromatherapy and MassageUnlike 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
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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essential oils, extracted from plants, are applied in a variety of ways
including directly to the skin through massage, by adding a few
drops to baths or by inhalation (for example, heated in an oil
burner)39.
The review found evidence that aromatherapy might reduce
agitation, neuropsychiatric symptoms and wandering. In line with
NICE clinical guidelines, the evidence suggests that carers may
consider use of aromatherapy for the person they care for. Within
the studies reviewed aromatherapy was used in a variety of ways.
These included the use of essentials oils with massage by a trained
practitioner, essential oils in a diffuser in the air and drops of oils
placed on bedding or to clothes. The majority of studies looked at
use of lemon balm or lavender oil; indeed lavender is considered to
be the safest oil to 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 lavender
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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oil to a bath43 or giving a hand massage, again using a scented oil
such as lavender44.
While, as suggested earlier, advice should be taken over which oils
are most appropriate to use (massage is discuss in more detail in
later) carers might try introducing aromas into the home
environment to facilitate a calm or soothing environment through,
for example, fresh flowers or pot pourri. The sense of smell might
also be stimulated through visits to garden centres or flower
shows45.
Massage and touch
Evidence from the review suggests that massage or touch therapies
work in reducing agitation; that hand massage; music followed by
hand massage or music and massage simultaneously each for 10
minutes can have an immediate effect and short term reduction in
agitated behaviour; and that gentle touch on the forearm
accompanying verbal encouragement can encourage eating.
As highlighted earlier, sensory experiences are important. NICE
suggest that massage is delivered by someone with appropriate
training and this may be something that carers seek advice from
specialist practitioners on46. The person being cared for may enjoy
hand, neck and foot massage47, it may be used as a calming activity
when a person is, for example, agitated or provide a distraction
when confused or restless. Carers might want to contact
practitioners of massage in order to learn appropriate massage
techniques.
43 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
44 http://www.alzheimers.org.uk/factsheet/505.
45 http://www.alzheimers.org.au/upload/HS2.5.pdf
46 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=420&pageNumber=1
47 http://www.alzheimers.org.au/upload/HS2.5.pdf
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Whilst massage and massage techniques maybe useful, simple
techniques that involve physical contact and touch are important
and may be used to help the person being cared for, both in
preventing unusual behaviour and as a coping strategy for the carer
during those behaviours. These sensory techniques might involve
simply touching or gently stroking a person’s hand, or brushing their
hair. As the Alzheimer’s Society note, even when conversation
becomes more difficult, being warm or affectionate can help carers
to remain close to their loved ones, or for the person with dementia
to feel supported. Communicate your care and affection by the tone
of your voice and the touch of your hand. Don't underestimate the
reassurance you can give by holding or patting the person's hand or
putting your arm around them, if it feels right48.
When a reaction occurs, for example, if the person being care for
becomes agitated or aggressive one coping strategy may be to stay
calm and gently hold their hand or to put your arm around them49.
Similarly, in coping with hallucinations, touching and talking in a
calm and reassuring way may bring the person back to reality50 and
gentle patting might distract the person’s attention and reduce the
hallucination51. However, whilst touch can provide reassurance, be
calming and provide a distraction it is advisable to try to avoid
restraining or preventing someone with dementia from moving
about when they are feeling agitated or nervous52 and that the
touch is not interpreted as a form of restraint.
In addition to the use of gentle touch for preventing or coping with
unusual behaviour, depression may also respond to more one-to-
one interaction, such as talking, hand holding, or gentle massage53.
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
53 http://www.alzheimers.org.uk/factsheet/444
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The following box highlights some techniques carers might like to
try.
A hand massage using scented oil can be very soothing. Try a
hand massage using lavender or lemon balm ; music followed by a
hand massage or music and a hand massage for 10 minutes to
reduce agitation
A calming environment may help to avoid difficult behaviours
such as aggression or agitation. Try using different aromas: an oil
burner infused with a few drops of scented oil, fresh flowers or pot
pourri
Try reducing difficult behaviours at bath time by adding few
drops of scented oil in the bath
Try stimulating sense of smell though visits to garden centres
or flower shows
In coping with unusual behaviours such as agitation offer
reassurance, by touching and holding or try to distract the person,
using a calming activity such as a hand massage54 or brushing the
person’s hair
When becoming confused, restless or insecure the person with
dementia may find a back rub calming55
For those people being cared for who are depressed try more
one-to-one interaction, such as talking, hand holding, or gentle
massage, if appropriate56.
Where the person may do or say something over and over
again (repetition) reassure them with a calm voice and gentle
touch57.
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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Try a gentle touch on the forearm together with verbal
encouragement to encourage eating
If the person with dementia is experiencing a hallucination try
touching and talking to the person in a calm and reassuring way – it
might help bring the person back to 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
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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symptoms should be offered an assessment at the earliest
opportunity that includes behavioural and functional analysis. As a
result of this assessment an individually tailored care plan is
formulated that can help carers.
SIGN (2006) note that behaviour management may be used to
reduce depression in people with dementia. This recommendation is
based in part on the randomised controlled trial included on the
Varkaik (2005) review that showed those with Alzheimer’s living at
home with depression are less depressed when their caregivers are
trained in using behaviour therapy-pleasant events or behaviour
therapy-problem solving.
Cognitive Stimulation Therapy /Cognitive Training
General cognitive stimulation involves a range of group activities
and discussions aimed at enhancing cognitive and social
functioning; similarly cognitive training involves guided practice on
a set of standard tasks designed to reflect memory, attention,
language or executive function (Clare and Woods 2004).
The review points to potential benefits from cognitive rehabilitation
and training – that it might work for improving memory, cognitive
functioning, neuropsychiatric symptoms, behaviour, depression,
quality of life, learning, and activities of daily living. Whilst the
evidence is inconclusive there are encouraging results for learning
memory, executive functioning, activities of daily living, general
cognitive problems, depression and self-rated general functioning
(Sitzer et al, 2006).
Carers may wish to consider accessing locally cognitive stimulation
programmes for those they care for. NICE guidelines state that
people with mild to moderate dementia should have the opportunity
to participate in a structured group cognitive stimulation
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programme commissioned or provided by health and social care
staff with appropriate training and supervision. Similarly SIGN
recommend that cognitive stimulation be offered to individuals with
dementia.
Counselling
The review found no evidence that counselling works for improving
recall, logic memory or learning for people with dementia. However,
this statement should be tempered with the caveat that only one
randomised controlled trial was identified within the review and this
had a small sample size (Bates, 2004).
All the dementia organisations included in this part of the report
referred to counselling and/or cognitive behaviour therapy in the
treatment of depression for people with dementia. Carers might like
to discuss the availability and appropriateness of these therapies
with the doctor looking after the person with dementia. However, as
Alzheimer Europe note, any kind of therapy which relies on verbal
communication will only be suitable for a small number of people
suffering from dementia or those in the early 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).
61 http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE
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Within the review the environmental changes were diverse; they
included the use of mirrors, sign-posting and access to outdoor
areas. The absence of robust studies meant it was only possible to
conclude that environmental manipulation might work for improving
neuropsychiatric symptoms and decreasing agitation and
wandering. Additionally, studies included in the review were based
in residential or institutional settings and as such may not be easily
transferable to a home setting.
This sub-section describes changes that could be made by carers in
the home that might be useful in addressing behavioural and
psychiatric symptoms of dementia. The suggestions include
changes in lighting but it is important to note that these changes
are not bright light therapy (which involves exposure to intense
levels of light under controlled 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.
62 http://www.columbia.edu/~mt12/blt.htm63 http://www.alzheimers.org.uk/downloads/non_pharmacological_therapies.pdf64 http://www.alz.org/alzheimers_disease_10429.asp
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In order to help alleviate behaviours such as agitation, aggression or
anxiety it is thought important to create a calming and relaxing
environment. There are a number of different suggestions that
carers may like to try. The over-riding principle of these strategies is
to simplify the home environment in order to reduce confusion
through changes in lighting, removal or relocation of mirrors or even
creating a special place designed for relaxing. Whilst these visual
elements are important so too are audio elements in the home
which can trigger difficult behaviours or symptoms. Lower noise
levels or removal of competing noises can also help create a
calming environment by removing excess stimulation. In addition
communication may be improved by avoiding competing noises
such as television or 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
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=27169 http://www.alz.org/national/documents/topicsheet_hallucinations.pdf.
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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 with dementia recognise where they are when
they wake up72 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
70 http://www.alz.org/living_with_alzheimers_bathing.asp
71 http://www.alzheimers.org.au/upload/HS5.5.pdf72 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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Ensure lighting is adequate as shadows, glare and reflections
can be confusing or frightening
Mirrors can be a source of hallucination; consider taking them
down,r covering them up or moving them
Use nightlights to aid sleep and provide reassurance
Furnish a special room or place for relaxing with calming items
including for example, comfortable seating, calming music and
plants or flowers
Music and Music Therapy
Even when other abilities are seriously affected people may still
enjoy singing, dancing and listening to 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
77 http://www.alzheimers.org.uk/factsheet/50578 http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271
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aggression or as a vehicle for communication. Music therapy
typically involves playing music for up to 30 minutes in a quiet room
with someone present for at least some of the time (to make sure
the person with dementia is comfortable and happy with the level of
sound)79. This could be tried at home. Carers could try joining the
person being cared for in listening to the music making it a shared
experience, an opportunity for both the carer and the person being
cared for to relax 80 and chat. The music can provide a focus for
conversation.
The Alzheimer’s Association suggest use of live music, tapes or CDs
as radio programs, interrupted by commercial breaks, can cause
confusion81. 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
79 http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=27180 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
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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 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
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
88 http://www.alzheimers.org.au/content.cfm?infopageid=4187
89 http://www.alzheimers.org.au/content.cfm?infopageid=4187
90 http://www.alz.org/living_with_alzheimers_music_art_and_other_therapies.asp#2
91 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
92 http://www.alzheimers.org.au/upload/HS5.5.pdf
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Try group music activities including listening,
singing and playing to reduce wandering
behaviour
Use music to encourage singing, clapping or even
dancing
Music can be used in the background to help reduce or
prevent difficult behaviours by creating a calming and relaxing
environment
Try using background music to aid eating. Having
background music or a radio playing can be
comforting, especially for those eating alone
Try playing background music at bath time.
Background music can help reduce agitation while
bathing
For those who have difficulties sleeping having a
radio or soothing background music playing softly
can aid sleep
Choice of music:
Play favourite music remembering that people
tend to relate best to music they were familiar
with when younger
Be aware that radio, interrupted by commercial
breaks can cause confusion
Choose the music to create the mood you want
Avoid over stimulation – look for signs of agitation
or irritation
Be alert for music that provokes unhappy
memories
Physical Exercise/Activity
The beneficial effects of a physically active lifestyle in health
promotion are well-documented (DH, 2004; WHO, 2004). The
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review evaluated the effect of physical activity/exercise on mood,
sleep, functional ability (activities of daily living), wandering,
agitation and cognitive function for those with dementia and the
evidence suggests that physical exercise does work. These findings
are echoed by NICE who recommend that exercise interventions are
made available to those with dementia who have depression and
anxiety. Similarly, SIGN suggest structured exercise can help
maintain mobility.
Strategies for increasing the physical activity of those with dementia
can be incorporated into the daily routine of both the person being
cared for and the person undertaking the caring. As illustrated in the
review the potential benefits are myriad. Regular exercise can
prevent or reduce the symptoms associated with dementia by using
up spare energy, acting as a distraction from difficult behaviours,
providing a sociable activity and giving routine and structure to the
day. As outlined earlier, physical activity can reduce the risk of
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-
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
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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 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
97 http://www.alzheimers.org.uk/factsheet/505
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
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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; 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
101 http://www.alzheimers.org.au/upload/HS2.5.pdf
102 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
103 http://www.alzheimers.org.uk/factsheet/444
104 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-europe.org/index.php?
lm3=BF4E655E2855&sh=10E410E5E107
105 http://www.alzheimer-europe.org/index.php?lm3=BF4E655E2855&sh=10E410E5E107
106 http://www.alzheimer-europe.org/index.php?lm3=BF4E655E2855&sh=F110C4B8AE93
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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
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
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
111 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-europe.org/index.php?
lm3=BF4E655E2855&sh=10E410E5E107
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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.
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
112 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6113 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6
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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, 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.
114 http://www.alzheimers.org.uk/factsheet/505
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
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Make a box of old objects that the person with dementia is
interested in. Physically handling things may trigger memories more
effectively than looking at 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 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
120 http://www.alzheimers.org.uk/factsheet/505
121 http://www.alzheimers.org.au/content.cfm?infopageid=4524
122 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6
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discuss the local availability and whether the intervention is
appropriate for the person they care for.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS involves the application of an electric current through
electrodes attached to the skin. Whilst TENS is typically used in pain
relief it has been posited that TENS, applied to the back or head,
may improve cognition and behaviour in those with dementia. The
review shows that TENS might work but concludes that there is
insufficient evidence to recommend its use.
For carers wishing to explore the use of TENS it is suggested that
they contact the healthcare professionals involved in the care of the
person with dementia to discuss the local availability and whether
the intervention is appropriate for the person they care for.
Validation Therapy
Validation is a method of communicating with and helping
disoriented people that is built on an empathetic attitude and a
holistic view of 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
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
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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 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
128 http://academic.evergreen.edu/curricular/hhd2000/Mukti's%20Notes/VALIDATION%20THERAPY.htm
129 http://www.alzheimer-europe.org/index.php?lm3=3410F410E7F5&sh=10710E43A3E6
130 http://www.alzheimers.org.uk/factsheet/526
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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 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
131 http://www.alzheimer-europe.org/index.php?lm3=2910C4678344&sh=ECE3B9A63711
132 http://www.alzheimer-europe.org/index.php?lm3=2910C4678344&sh=ECE3B9A63711
133 http://www.alz.org/national/documents/topicsheet_wandering.pdf
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Failure to recognise a person or mix up names can cause
agitation or anxiety. Whilst you might try explaining who the people
are it may be better to ignore the mistake and listen to what they
are trying to say.
Symptoms or Behaviour
The review in Section Two identifies the evidence of what non-drug
treatments work and what for. The symptoms or behaviours that are
addressed (as presented in Matrix 1) ranged from the specific
(agitation, anxiety) to the generic (behaviour, psychological
symptoms). In this part of the report these symptoms or behaviours
have been refined under key headings that emanate from both the
review and the suggested strategies from the dementia
organisations’ websites to present ideas about non-drug approaches
for dementia that those caring for a person with dementia might try
or might access locally. Under each heading is a description of the
symptom or behaviour together with the suggested strategy for
preventing or coping with it.
The dementia organisations all emphasise the importance of
creating a calming and relaxing environment and of using activities
to distract from difficult behaviours and relieve boredom which can
be a trigger for some difficult behaviours. As such this section
begins by providing a summary of general strategies for creating a
calming environment and activities that the carer might like to try
before going on to describe strategies to try for coping with or
reducing the occurrences of particular difficult behaviours and
symptoms.
Creating a Relaxing Environment
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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
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
134 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
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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 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.
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
138 http://www.alzheimers.org.uk/factsheet/505
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Music Activities
Music can be used as the focus of an activity:
Join the person with dementia in listening to music
making it a shared, relaxing experience that can
be enjoyed and talked about
Play favourite or soothing music or sing during
bath time
Try group music activities including listening,
singing and playing
Use music to encourage singing, clapping or even
dancing
Choice of music:
Play favourite music remembering that people
tend to relate best to music they were familiar
with when younger
Be aware that radio, interrupted by commercial
breaks can cause confusion
Try using music as the focus of an activity to help
prompt happy memories and stimulate
conversation but be alert for music that provokes
unhappy memories
Choose the music to create the mood you want
Avoid over stimulation – look for signs of agitation
or irritation
Pets
An activity such as stroking or grooming a pet can provide
that 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.
139 http://www.alzheimers.org.uk/factsheet/525
140 http://www.alzheimers.org.au/upload/HS2.5.pdf
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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
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
141 http://www.alzheimers.org.uk/factsheet/525
142http://www.alzheimers.org.uk/factsheet/444
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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
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
143 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-europe.org/index.php?
lm3=BF4E655E2855&sh=10E410E5E107
144 http://www.alzheimers.org.uk/factsheet/505
145 http://www.alzheimers.org.au/upload/HS2.5.pdf
146 http://www.alzheimers.org.au/upload/HS2.5.pdf
147 http://www.alzheimers.org.uk/factsheet/505
148 http://www.alzheimers.org.au/content.cfm?infopageid=4524
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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 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
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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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
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)
154 http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271155http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=7E655C216B76
156http://www.alzheimers.org.au/upload/HS5.1.pdf
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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
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.
157 http://www.alz.org/living_with_alzheimers_bathing.asp
158 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
159 http://www.alzheimers.org.au/content.cfm?infopageid=4515160 http://www.alzheimers.org.au/content.cfm?infopageid=4515
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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
Try using different aromas: an oil burner infused with a few
drops of scented oil, fresh flowers or pot pourri to prevent agitation
Help prevent agitation by adding a few drops of lavender oil to
a bath162
A hand massage using scented oil can be very soothing. Try a
hand massage using lavender or lemon balm ; music followed by a
161 http://www.alzheimers.org.uk/factsheet/525
162 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
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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 massage163 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
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
163 http://www.alzheimers.org.uk/factsheet/525
164 http://www.alzheimers.org.au/upload/HS5.9.pdf
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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.
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
165 http://www.alz.org/living_with_alzheimers_depression.asp
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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 supervision. Similarly
SIGN recommend that cognitive stimulation be offered to individuals
with dementia.
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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
contact166 (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
If the person being cared for fails to recognise
rather than drawing attention to the mistake,
provide help by explaining or demonstrating how 166 http://www.alzheimers.org.au/upload/HS2.5.pdf
167 http://www.alzheimers.org.au/content.cfm?infopageid=4464168http://www.alzheimers.org.uk/factsheet/444
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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
169 http://www.alz.org/living_with_alzheimers_hallucinations.asp
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validation therapy. In addition validation techniques to try at home
are detailed below
Things to try at home
Strategies thought to be of particular help in reducing the
occurrence or prevention or hallucinations are present below:
Offer reassurance, by touching and holding or try to distract
the person, using a calming activity such as a hand 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
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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a need to correct them make sure it is done
sensitively, in a way that saves face and shows
that you are not being critical
If the person being cared for fails to recognise
rather than drawing attention to the mistake,
provide help by explaining or demonstrating how
it is used, but if your explanation is not accepted
don’t argue
If the person being cared for fails to recognise a
person or mix up names. Whilst you might try
explaining who the people are it may be better to
ignore the mistake and listen to what they are
trying to say
Sleeplessness
Sleeplessness can be caused by a number of different factors
including sleeping through the day due to boredom or inactivity, or
simply due to insufficient energy expenditure. Again refer to the
subsections dealing with activities and creating a calm environment
for general strategies .
Accessing interventions:
Carers might like to access practitioners of bright light therapy
which it has been suggested can help reduce sleeplessness. Contact
the health care practitioners involved in the care of the person with
dementia to discuss availability and appropriateness of this type of
therapy.
Things to try at home:
Use nightlights to aid sleep and provide reassurance if awake
Music can be used as sleep inducing strategy either by playing
soothing music173 or by having a radio playing softly
173 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
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Boredom can be addressed using a range of activities (see
activities subsection)
Excess energy and boredom may be addressed by increasing
physical activity (see activities subsection).
Wandering
Wandering may be due to a variety of cause including a changed
environment, a loss of memory, excess energy, boredom, confusion
of day with night, agitation, or discomfort or pain174. It may be the
result of stress or anxiety or the side effects of medication175
Agitation and anxiety are dealt with in a separate subsection and
the reader should consult suggestions in those sections along with
the suggested techniques described here.
Accessing interventions:
Carers might consider accessing training courses for
behaviour management techniques locally through their health care
providers. Carers can also ask for an assessment of key factors that
may improve challenging behaviour in those they are caring for. The
NICE clinical guidelines are clear that that people with dementia
who develop non-cognitive symptoms should be offered an
assessment at the earliest opportunity that includes behavioural
and functional analysis. As a result of this assessment an
individually tailored care plan is formulated that can help carers.
People caring for a person with dementia might want to
access music therapy and several organisations provide group (and
individual) music activities. Details of activities available locally are
accessible on websites such as http://www.nordoff-robbins.org.uk/or
may be available through local health care providers. If there is a
particular time of day when the person being cared for becomes
agitated try scheduling music therapy just before that time176.174 http://www.alzheimers.org.au/content.cfm?infopageid=4465175 http://www.alz.org/living_with_alzheimers_wandering_behaviors.asp
176 http://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=271
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Carers wishing to explore the use of MSS can contact the
healthcare professionals involved in the care of the person with
dementia to discuss the local availability and whether the
intervention is appropriate for the person they care for.
Things to try at home
The subsection on activities addresses strategies to alleviate
boredom and cope with excess energy whilst, similarly the creating
a calming and relaxing environment provides more general
strategies.
Try using essential oils in a diffuser in the air or drops of oils
placed on bedding or to clothes. It is recommended that the use of
aromatherapy be discussed with a qualified aromatherapist who can
advise on the contraindications associated with different essential
oils.
For night time wandering use nightlights to aid sleep and
provide reassurance
For night time wandering music might be used as sleep
inducing strategy either by playing soothing music177 or by having a
radio playing softly.
177 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf
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SECTION FOUR
Conclusions and Implications for Carers
The aim of this report is to help informal carers who want ideas
about non-drug approaches for dementia, that they might try or that
they could try to access. The first part of the report focused on
three questions.
What non-drug treatments work and what do they work for?
The evidence presented in the systematic review suggests three
different interventions are effective for people with dementia. Music
or music therapy, hand massage or gentle touch and physical
activity or exercise. However even for these interventions the
evidence is mixed or limited. For example, within the papers
exploring music or music therapy methodological limitations were
highlighted that included weak study designs and small sample
numbers. Similarly evidence was presented for the use of massage
or touch therapies and whilst there is evidence to suggest massage
or touch therapies do work in a reducing agitation in the short term
and can help with eating there was no conclusive evidence that
massage reduces wandering, anxiety or aggressiveness.
The evidence from the review dovetailed with the information given
by the dementia organisations. All the dementia organisations
suggested strategies that include music, physical activity or
exercise and touch or massage.
What non-drug treatments might work and what for?
The majority of interventions fell into the ‘might work’ category due
to inconclusive results (AAT, Aromatherapy, Behaviour
Management, Cognitive Stimulation, Environmental Manipulation,
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Light Therapy, Reality Orientation, Reminiscence Therapy, MSS,
TENS, Validation Therapy). The lack of firm evidence arose for a
number of reasons including conflicting results and weakness in
study design. The implication for carers is that whilst some of these
interventions might be useful in managing symptoms of dementia
the evidence is not strong enough to support their use. However,
some of the interventions in this group formed the backbone of the
suggested coping/prevention strategies included in the dementia
organisations’ websites. This can be illustrated using reminiscence
therapy. Reminiscence therapy involves discussion of past
activities, events and experiences. The evidence showed that this
type of therapy has potential benefits in terms of cognition, mood
and general behaviour but the evidence rests on trials with small
sample sizes and of relatively low quality and there was variation in
the type of reminiscence work reported. The suggestions included in
the dementia organisations’ websites such as talking over past
events, looking through old photos or listening to old music all
replicate the activities that form the essence of reminiscence
therapy. The reasons for using these activities whilst worded more
pragmatically did echo those of the review. The websites often
didn’t mention ‘reminiscence therapy’ per se but rather
recommended that these might be enjoyable activities (improve
mood), that they might provide a distraction from difficult
behaviours (general behaviour) or be a way of relaxing or
stimulating conversation (cognition).
What non-drug treatments do not work?
There was no evidence to suggest beneficial effects for only two
interventions, acupuncture and counselling. Only one paper was
found that attempted to explore the use of acupuncture (Peng et al,
2007) but unfortunately no studies met their criteria. This is
particularly interesting given that acupuncture is one of the most
popular complementary therapies in the UK (Smallwood, 2005).
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However, in line with the paucity of evidence for its use for people
with dementia none of the dementia organisations suggested its
use.
Counselling was included in one paper which reviewed psychosocial
interventions for people with milder dementing illness (Bates et al,
2004). The review identified just one randomised controlled trial and
reported that counselling provided an opportunity for the client to
vent their concerns and receive validated information about their
mental status; but the effectiveness of individual counselling
sessions was not demonstrated on the outcome measures used
(recall, logical memory, learning). Whilst no evidence was included
for recall logic, memory and learning, all the dementia organisations
included in this part of the report referred to counselling and/or
cognitive behaviour therapy in the treatment of depression for
people with dementia. Although Alzheimer Europe note, any kind of
therapy which relies on verbal communication will only be suitable
for a small number of people suffering from dementia or those in
the early 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
178 http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE
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that there were parallels between them. An example of this is the
advice given not to correct misplaced beliefs which clearly has
parallels in validation therapy.
It is important to note that the focus of these suggestions lies in
behaviour and psychological symptoms. This is unsurprising given
that virtually all patients with dementia will develop changes in
behaviour as the disease progresses (Rayner et al, 2006, p647).
Whilst the suggested strategies appear to be general, rather than
specific across many behaviours consensus opinion is that the
incidence of distress whether manifest in aggression, anxiety or
sleeplessness can be ameliorated by a calming environment,
structured activities and redirection or distraction (Lavretsky and
Nguyen, 2006). The dementia organisations present a far more
holistic picture than the evidence presented in the review. Whilst
the focus of individual evaluations in the papers included in the
review tended to be a single intervention all the dementia
organisations emphasised the importance of a calming and relaxing
environment with structure and routine (and how interventions and
activities can help achieve this). This could have been anticipated
given the nature of the research process and the complexity of
evaluating multiple interventions.
A caveat in taking forward the strategies described here is to
highlight that the focus of this report has been on coping or
preventative strategies. The reported has alluded to triggers for
these behaviours but it is important to emphasise that the
strategies carers can try will be better informed by insight into the
likely causes of that behaviour or symptom. Triggers can be a result
of illness, the side effects of medication or physical discomfort.
Changed behaviours or symptoms should be discussed with the
health care professionals involved in the care of the person with
dementia to eliminate these possibilities.
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Implications for Future Research
As highlighted earlier, overall the studies included in the reviews
were characterised by weak study designs and small sample sizes.
Indeed three reviews were unable to identify any studies of
sufficient quality to assess (the study inclusion criteria for Hermans
et al (2007) and Peng et al (2007) included only randomised
controlled trials; Price et al (2001) also included controlled trials and
interrupted time series).
Many of the reviews included single person case studies or studies
of less than five people. Whilst it is not possible to generalise about
the effectiveness of different interventions many pointed to
potential benefits from the intervention being assessed. The
randomised controlled studies included in the reviews were of mixed
quality and the meta-analyses were often limited by the small
number of studies, and thus data, included.
Another area of concern was the range of the interventions under
each ‘category’ which hampered analyses. For example, Sitzer et al
(2006) carried out a meta-analysis of cognitive training that
produced encouraging results but the interventions included in the
analysis, under the umbrella of cognitive training, were diverse and
the review did not point to the effectiveness of any one type of
cognitive training. Measurement of outcomes was also highlighted
as an area of concern by some reviews who pointed to the need for
consistency in how outcomes are measured and use of validated
outcome measures.
Many of the studies included were based in community residential
settings (for example, in nursing homes). Given the increasing
number of people now caring for people with dementia in their own
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home there is a clear need to ensure that research is transferable to
this setting. Indeed, the IPA note that further research is need to
explore the relationship of behavioural and psychological symptoms
of dementia to the environments in which they occur (IPA, 2002,
p7).
Taken together, whilst the volume of studies in this area is
encouraging the review points to the need for large, well designed,
randomised controlled studies rather than the seemingly piecemeal
approach taken at present.
Implications for Service Providers and Commissioners
Of the 16 interventions identified, evidence exists for the benefits of
three interventions for people with dementia: physical activity,
music or music therapy and massage or gentle touch. The evidence
is inconclusive for a further eleven. Whilst, as described earlier,
carers can apply some of these interventions in the home setting at
little or no cost to health or social care services (for example,
playing favourite music), others are likely to require training (for
example in hand massage) or instruction (for example, in
appropriate exercise routines). In addition both service providers
and commissioners should explore current and future provision of
more structured group activities for people with dementia in line
with the evidence presented; in particular the provision of group
music therapy and group exercise activities that meet the needs of
both the person with dementia and their carer.
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Matrix 1a. Interventions and Symptoms Evidence Assessment: 0=Evidence of effectiveness; 1= No evidence of effectiveness; 2=inconclusive evidence
Aggression Agitation
Anxiety Apathy Behaviour Cognitive Function
Communi-cation
Depression Emotional & Behavioural Responses
Functional Ability
Inappropriate behaviour
Learning Memory
Acupuncture(no studies included)Animal Assisted Therapy
2 2
Aromatherapy 2
Behaviour Management
2 2 2
Cognitive stimulation /
rehabilitation / training
2 2 2 2
Counselling 1 1
Environment Manipulation
2 2
Light Therapy 2 2 2
Massage / Touch
2 0 2
Music / music therapy
0 0 0 0 0
Physical activity / exercise
2 2 2
Reality orientation
2 1 2 1 2 1
Reminiscence therapy
2 2 2 2
Snoezelen / multi-sensory stimulation
2 2 2 2 1 2 2 2
TENS 2 2 2
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Validation therapy
1 1 2 1 2 2
Matrix 1b. Interventions and Symptoms: 0=Evidence of effectiveness; 1= No evidence of effectiveness; 2=inconclusive evidence
Leeds Institute of Health Sciences July 2008
Mood Neuropsychiatric Symptoms
Nutrition
Psychological Symptoms
Quality of Life / Well-being
Recall Sleep Social Behaviour
Wandering
Acupuncture
Animal Assisted Therapy
2 2
Aromatherapy 2 2
Behaviour Management
2 1
Cognitive stimulation /
rehabilitation / training
2 2
Counselling 1
Environment Manipulation
2
Light Therapy 2 2 2
Massage / Touch 0 2Music / music
therapy0 0 0 0
Physical activity / exercise
0 0 0
Reality orientation 1Reminiscence
therapy2
Snoezelen / multi-sensory
stimulation
1 2 2 2
TENS
Validation therapy
2
120
Table 1. Acupuncture: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Author,
YearOverall
assessment of the review
Research Question
Years covered
Search terms used
Databases searched
No of studies
reviewed
Author’s Conclusions on Counselling Study
Comments
Peng 2007 ++ What is the efficacy and
possible adverse effects of
acupuncture therapy for
treating vascular dementia?
Search carried
out February 2007. No details of
date restriction
s
Acupunct* Specialised Register contained records from : CENTRAL,
MEDLINE, EMBASE, PsycINFO, CINAHL,
SIGLE, LILACS, ISTP, INSIDE, plus these,
on-going trials
0 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
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Table 2a . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT). Author,
YearOverall assessment of
the review
Research Question
Years covered
Search terms used
Databases searched
No of studies review
ed
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
11 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 criteriaSome aspects of study design
not clear – for example randomisation; small sample
sizes, selection criteria is likely to overestimate results
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Table 2b . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT). General Review Including AATAuthor,
YearOverall assessment of
the review
Research Question
Years covered
Search terms used
Databases searched
No of AAT
studies review
ed
Author’s Conclusions Comments
Cohen-Mansfield 2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of non-pharmacological 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 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).
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Table 3a. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT). Author,
YearOverall assessment of
the review
Research Question
Years covered
Search terms used
Databases searched No of studies review
ed
Author’s Conclusions
Comments
Thorgrimsen 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
.nih.gov/, National Research Register, ClinicalTrails.gov,
LILACS, http://www.forestclinical
trials.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
2 (all RCTs)
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.
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Table 3b. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Aromatherapy
Author,Year
Overall assessment of
the review
Research Question
Years covered
Search terms used
Databases searched No of aromatherapy studies review
ed
Author’s Conclusions
Comments
Robinson 2006 / 2007 (two
papers reporting
same study)
++ To determine the clinical and cost
effectiveness and acceptability of
non-pharmacological 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
2 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.
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
Medline, Research Council for
Complementary Medicine, PsycINFO,
Ingenta plc, Cochrane Database of Systematic
Reviews
7 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
Likely to overestimate results as study quality is not
assessed – all appear to have been given equal weight
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Table 4. Behaviour Management: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Individualised Behaviour Management
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used Databases searched No of studies
reviewed
Author’s Conclusions Comments
Robinson 2006 /
2007 (two papers on
same study)
++ To determine the clinical and cost effectiveness and
acceptability of non-pharmacological
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
1 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.
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)
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.
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Table 4 (cont). Behaviour Management: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Individualised Behaviour Management
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used Databases searched No of studies
reviewed
Author’s Conclusions Comments
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.
1 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 therapy-problem 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
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Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT). Author,
YearOverall
assessment of the review
Research Question Years covered Search terms used Databases searched No of studies
reviewed
Author’s Conclusions Comments
Clare 2007 ++ 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
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
9 (all RCTs)
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.
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.
Grandmaison 2003
+ To review the evidence on the
efficacy of stimulation
strategies or programmes with the AD population
As indicated by database
Numerous search terms
outlined in textClear
inclusion/exclusion criteria
Medline (1971), PsychINFO (1887-2001)
17 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 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.
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128
Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: 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
Author’s Conclusions Comments
Sitzer 2006 ++ 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)
19 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).
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Table 5b. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used
Databases searched No of cognition studies reviewed
Author’s Conclusions Comments
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
1 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.
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
Livingston2005
+ 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)
4 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 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.
Table 6. Counselling: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Counselling
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130
Author,Year
Overall assessment of
the review
Research Question Years covered
Search terms used
Databases searched No of counselling
studies reviewed
Author’s Conclusions on Counselling Study
Comments
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
1 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
Table 7. Environmental Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Environmental Interventions
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131
Author,Year
Overall assessmen
t of the review
Research Question Years covere
d
Search terms used
Databases searched
No of studies reviewed
Authors’ Conclusions Comments
Livingston2005
+ 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)
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.
Cohen-Mansfield 2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of non-pharmacological 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
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).
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132
Table 7 (cont) . Environmental Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Environmental Interventions
Author,Year
Overall assessmen
t of the review
Research Question Years covere
d
Search terms used
Databases searched
No of studies reviewed
Authors’ Conclusions Comments
Spira 2006 - To critically review the empirical literature on
behavioural interventions to reduce agitation in older adults
with dementia
1970-2004
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.
Table 8a. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
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133
Author,Year
Overall assessment
of the review
Research Question
Years covered Search terms used
Databases searched No of studies
reviewed
Author’s Conclusions Comments
Forbes 2007
++ What recommendations can be made regarding the
efficacy of light therapy in managing
disturbances of sleep,
behaviour, mood and/or
cognition associated with
dementia?
Search carried out December
2005
Bright light*, light box*, light visor*,
dawn-dusk*, phototherapy
(MESH), phototherapy,
“phototherapy”, “light therapy”,
“light treatment”, light*
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
5 (all RCTs)
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.
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
MEDLINE, PsycINFO, Cochrane
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.
Table 8a (cont). Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Leeds Institute of Health Sciences July 2008
134
Author,Year
Overall assessment
of the review
Research Question Years covered Search terms used Databases searched No of studies
reviewed
Author’s Conclusions Comments
Kim 2003 - To evaluate the effects of bright light therapy on the sleep
and behaviour of dementia patients
No clear Not reported Not reported 14 A need clearly exists for well-designed
controlled studies to look at the relationship
among dementia, agitation, sleep-
wakefulness 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.
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135
Table 8b. Light Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Light TherapyAuthor,
YearOverall
assessment of the review
Research Question
Years covered Search terms used Databases searched No of light
studies reviewed
Author’s Conclusions Comments
Cohen-Mansfield 2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of non-pharmacologic
al 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
7 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).
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136
Table 9a. Massage and Touch: Key Characteristics of included systematic reviews (including at least one RCT). Author,
YearOverall
assessment of the review
Research Question Years covered Search terms used Databases searched No of studies
reviewed
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.shtml, ISRCTN Register, IPFMA
Clinical Trials Register,
2 (both RCTs)
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.
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137
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
Overall assessmen
t of the review
Research Question Years covered Search terms used Databases searched No of studies
reviewed
Author’s Conclusions Comments
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)
3 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.
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.
Cohen-Mansfield 2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of non-pharmacological 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 Massage touch: 6 studies, one
reported unequivocal
success, the others either a positive
trend, partial effects (physical
and verbal behaviours) or no effect (aggression)
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).
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138
Leeds Institute of Health Sciences July 2008
139
Table10a. Music Therapy Reviews: 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
Author’s Conclusions Comments
Sung 2005 ++ 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,
8 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
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
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) 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 inclusion of only
RCTs
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140
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 Search terms used Databases searched No of studies
reviewed
Author’s Conclusions Comments
Sherratt 2004
+ 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
21 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
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 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
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
141
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
Search terms used
Databases searched No of music therapy studies
reviewed
Author’s Conclusions on Music Therapy Study
Comments
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
1980 – present (assume 2002)
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
19 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
142
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 No of music therapy studies
reviewed
Author’s Conclusions on Music Therapy Study
Comments
Robinson 2006, 2007 (two papers report same
study)
++ To determine the clinical and cost effectiveness and
acceptability of non-pharmacological 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
1 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.
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
Cochrane Database of Systematic Reviews (on
CD-ROM)Medline [see search
strategy]Embase [see search
strategy]Other databases (e.g.
PsycInfo) as appropriateCentre for Reviews and Dissemination (CRD)
websiteDatabase of Abstracts of
Reviews of Effects (DARE) online database
Health Technology Assessment (HTA) online
databaseNational Institute for Health and Clinical
Excellence (NICE) websiteTRIP online database
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
143
Leeds Institute of Health Sciences July 2008
144
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 No of music therapy studies
reviewed
Author’s Conclusions on Music Therapy Study
Comments
Livingston2005
+ 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)
24 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
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.
Watson 2006
+ Is there evidence for any effective
interventions to assist older people with dementia to feed?
Up to December
2003
feeding, eating,
dementia, mealtimes
CINAHL, Medline, EMBASE and Cochrane
13 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.
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
145
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 No of music therapy studies
reviewed
Author’s Conclusions on Music Therapy Study
Comments
Cohen-Mansfield
2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of
non-pharmacological 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
11 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
146
Table 11a. Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author,Year
Overall assessmen
t of the review
Research Question
Years covere
d
Search terms used Databases searched
No of studi
es reviewed
Author’s Conclusions Comments
Eggermont 2006
++ To evaluate the effect of planned physical activity
programmes 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
27 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
147
Table 11a (cont) . Exercise/Physical Activity Reviews: Key Characteristics of included systematic reviews (including at least one RCT).
Author,Year
Overall assessmen
t of the review
Research Question
Years covere
d
Search terms used Databases searched
No of studi
es reviewed
Author’s Conclusions Comments
Penrose 2005
- To appraise published literature
on the role of
exercise, including aerobic
and resistance training ,
in maintainin
g or improving
the cognitive
function of persons
with Alzheimer’s disease
Up to December 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
Unclear
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
148
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
Overall assessm
ent of the
review
Research Question
Years covered
Search terms used
Databases searched No of exercis
e studies review
ed
Author’s Conclusions Comments
Robinson 2006 / 2007 (two papers
on same study)
++ To determine the clinical and
cost effectiveness
and acceptability
of non-pharmacologic
al 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
1 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.
Livingston2005
+ 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)
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
149
Leeds Institute of Health Sciences July 2008
150
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
Overall assessm
ent of the
review
Research Question
Years covered
Search terms used
Databases searched No of exercis
e studies review
ed
Author’s Conclusions Comments
Cohen-Mansfield
2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of non-pharmacologic
al 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
4 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
151
Table 12. Reality Orientation Interventions: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reality Orientation
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used
Databases searched No of studies
reviewed
Author’s Conclusions Comments
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)
11 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.
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
2 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.
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
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 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 a comprehensive review; however, there is no discussion of the
strength of evidence for no effect / negative effect - only positive effect
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152
Table 13a. Reminiscence Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reminiscence Therapy
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used
Databases searched No of studies
reviewed
Author’s Conclusions Comments
Warner 2006
++ 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 databaseHealth Technology Assessment
(HTA) online databaseNational Institute for Health and
Clinical Excellence (NICE) websiteTRIP online database
1 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 Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE, ISTP, INSIDE, plus Theses and on-going trials. Full details included in paper
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
153
Table 13b. Reminiscence Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Reminiscence Therapy
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used
Databases searched No of studies
reviewed
Author’s Conclusions Comments
Livingston2005
+ 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)
5 Assigned a grade equivalent to troublingly
inconsistent or inconclusive studies. Of the three RCTs included
one found a non-significant improvement
when reminiscence therapy was preceded by reality orientation but not vice versa; the other found no benefit
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.
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.
2 One RCTof low quality reports significantly lower self-reported
depression at post-test (but was higher than control at baseline).
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
154
Table 14a. Snoezelen Therapy/Multisensory Stimulation: 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 No of studies reviewed
Author’s Conclusions Comments
Chung 2002
++ What is the efficacy of snoezelen as a
therapeutic intervention for older
people with dementia?
Original review 2002;
subsequent update 2004.
No date exclusion
Trials identified from the
Specialised Register of
the Cochrane Dementia
and Cognitive
Improvement Group using
the terms snoezelen,
multi-sensory
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, Lundbeck Clinical Trial Registry
3 papers representing two trials (all
RCTs)
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.
Lancioni 2002
- Examining within-session, post-session
and longer-term effects of snoezelen
with people with developmental disabilities and
dementia
No details given
No details PSYCLIT, Medical Express 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 within-
session 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
155
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
Author’s Conclusions Comments
Robinson 2006 /
2007 (two papers on
same study)
++ To determine the clinical and cost effectiveness and
acceptability of non-pharmacological
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
3 Some evidence, albeit of poor quality, for the
effectiveness of multi-sensory 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.
Clear review with comprehensive description of methodology, literature and findings. The conclusions are in
line with the findings.
Livingston2005
+ 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 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
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
156
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 No of snoezelen / multi-sensory studies
reviewed
Author’s Conclusions Comments
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.
3 There is some evidence (from 2 high quality RCTs) that multi-
sensory stimulation/Snoezelen
in a multi-sensory room reduces apathy in people in the latter stages of dementia.
Overall a comprehensive review; however, there is no discussion of the
strength of evidence for no effect / negative effect - only positive effect
Cohen-Mansfield 2001
- Considers inappropriate behaviours in dementia; a
literature search on the impact of non-pharmacological 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
4 Most studies report improvement though it
is not necessarily statistically significant
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
157
Table 15. TENS: 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 exercise studies
reviewed
Author’s Conclusions Comments
Cameron 2003
++ 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
9 (of which 3 included in meta
analysis)
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,
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
158
insufficient data to
recommend use.
Leeds Institute of Health Sciences July 2008
159
Table 16a. Validation Therapy: 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 exercise studies
reviewed
Author’s Conclusions Comments
Neal 2003 ++ 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.shtml, ISRCTN Register
3 (all RCTs)
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.
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Table 16b. Validation Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General Reviews that included Validation Therapy
Author,Year
Overall assessmen
t of the review
Research Question Years covered Search terms used Databases searched No of exercise studies
reviewed
Author’s Conclusions Comments
Livingston2005
+ 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)
3 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
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.
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.
4 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; however, there is no discussion of the
strength of evidence for no effect / negative effect - only positive effect
Table 17. Characteristics of included systematic reviews that did not identify any studies for inclusion
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Author,Year
Overall assessment of
the review
Research Question
Years covered
Search terms used
Databases searched No of studies
reviewed
Author’s Conclusions
Comments
Herman 2007
++ Evaluating the effectiveness and safety of non-pharma
interventions in reducing
wandering in domestic settings
Search conducted May 2006. No explicit
date exclusion
Exit*, wander* or elopement or ambulat* or
walk*
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
0 N/A N/A.
Peng 2007
++ What is the efficacy and
possible adverse effects of
acupuncture therapy for treating vascular dementia?
Search carried out February 2007. No
date exclusion
Acupunc* Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE,
LILACS, plus conference proceedings, theses and on-going
trials
0 N/A N/A
Price 2001
++ To review non-drug / non-physical
barriers to reduce wandering in people with
acquired cognitive impairment
Search carried out
January 2007
Exit*, wander*, camouflage, bars, stripe*, grid*, floor*,
door*, barrier*, elopement, ambulat*
Specialised Register contained records from : CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, SIGLE,
LILACS, plus conference proceedings, theses and on-going
trials
0 N/A N/A
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Matrix 2a. Aggression Strategy
Organsiation
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
Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer* EuropeReview (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
Organsiation
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
Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer* EuropeReview (from section two)*
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Matrix 2c. Depression Strategy
Organsiation
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
Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer* EuropeReview (from section two)*
Matrix 2d. Hallucinations Strategy
Organsiation
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
Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer EuropeReview (from section two)*
*Hallucinations not referred to specifically
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Matrix 2e. Sleeplessness Strategy
Organsiation
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
Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer EuropeReview (from section two)
Matrix 2f. Wandering Strategy
Organsiation
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
Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer EuropeReview (from section two)
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Spira AP, Edelstein BA. Behavioral interventions for agitation in older adults with dementia: an evaluative review. Int Psychogeriatr. 2006 JunJun;18(2):195-225.
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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
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Woods B, Spector A, Jones C, Orrell M, Davies S. Reminiscence
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Alzheimer Association http://www.alz.org/index.asp
Alzheimer Europe http://www.alzheimer-europe.org/
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Baker, R., Bell, S., Assey, J., et al. 1998. A Randomised Controlled
Trial of the Snoezelen Mulit-sensory Environment for Patients with
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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
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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
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Clare L, Woods RT. 2003. Cognitive rehabilitation and cognitive
training for early-stage Alzheimer's disease and vascular dementia.
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impact of physical activity and its relationship to health. A report
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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
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sdrev/toc.asp)
Knapp, M., Prince, M., Albanese, E., Banerjee, S., Dhanasiri, S.,
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Koger, S., Brotons, M. 2000. Music Therapy for Dementia Symptoms.
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APPENDIX ONE (search strategies)
Searches run 7th November 2007
1. OVID AMED 1985 - Nov 2007:
1. exp *dementia/
2. exp delirium/
3. alzheimer$.tw.
4. creutzfeldt$.tw.
5. kluver$.tw.
6. (pick$ adj disease).tw.
7. huntingdon$.tw.
8. binswanger$.tw.
9. korsako$.tw.
10. wernicke$.tw.
11. or/1-10
12. review$.ti. or review$.ab.
13. ("review" or "review academic" or "review literature").pt.
14. 12 or 13
15. 11 and 14
16. limit 15 to yr="2001 - 2007"
2. OVID CINAHL 1982 – Nov 2007
1. exp Occupational Therapy/
2. Recreational Therapy/
3. exp *Rehabilitation/
4. exp Sensory Stimulation/
5. ((occupation$ or recreation$) adj2 (therap$ or intervention$)).tw.
6. ((art$ or music$ or danc$ or drama$ or craft$ or game$) adj2 (therap$ or intervent$)).tw.
7. ((book$ or exercis$ or work$ or vocational$ or swim$ or light$) adj2 (therap$ or intervent$)).tw.
8. bibliotherap$.tw.
9. snoezelen$.tw.
10. ((sound$ or noise$ or acoustic$) adj2 (stimulat$ or therap$)).tw.
11. dolls.tw.
12. or/1-11
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13. exp *psychotherapy/
14. (reality$ 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$)).tw.
5. exp kinesiotherapy/
6. vocational rehabilitation/
7. Recreational Therapy/
8. exp sensory stimulation/ or auditory stimulation/
9. exp psychotherapy/
10. ((art$ or music$ or danc$ or drama$ or craft$ or game$) adj2 (therap$ or intervent$)).tw.
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11. ((book$ 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$).ti.
36. 34 or 35
37. or/1-28
38. 37 and 33 and 36
39. limit 38 to yr="2001 - 2008"
4. OVID MEDLINE 1996 – Nov 2007
1. exp psychotherapy/
2. (reality adj2 orientat$).tw.
3. reality-orient$.tw.
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4. validation therapy.tw.
5. reminisce.tw.
6. reminiscence.tw.
7. (cogniti$ 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
34. exp Complementary Therapies/
35. aromatherapy$.tw.
36. acupunctur$.tw.
37. (sensory$ adj2 integrat$).tw.
38. reflexology$.tw.
39. herbal$.tw.
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40. ginkgo$.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$).ti.
56. 54 or 55
57. 53 and 56
58. limit 57 to yr="2001 - 2007"
5. OVID PSYCHINFO 2000 – Nov 2007
1. exp Occupational Therapy/
2. exp *creative arts therapy/
3. exp *exercise/
4. exp *games/
5. exp *psychodrama/
6. exp *phototherapy/
7. exp *vocational rehabilitation/
8. bibliotherap$.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/
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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/
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:
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[(dement* OR deliriu* OR alzheimer* OR creutzfeld* OR korsakoff*) in Title, Abstract or Keywords, from 2001 to 2007 in all products]
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APPENDIX TWO (data extraction template)
Methodology checklistA.1 Methodology checklist: systematic reviews and meta-analysesStudy identification
Include author, title, reference, year of publicationGuideline topic Key question no:Checklist completed by:SECTION 1: INTERNAL VALIDITYIn a well-conducted systematic review: In this study this criterion is:
(Circle one option for each question)
1.1 The study addresses an appropriate and clearly focused question.
Well covered Not addressedAdequately addressed Not reportedPoorly addressed Not applicable
1.2 A description of the methodology used is included.
Well covered Not addressedAdequately addressed Not reportedPoorly addressed Not applicable
1.3 The literature search is sufficiently rigorous to identify all the relevant studies.
Well covered Not addressedAdequately addressed Not reportedPoorly addressed Not applicable
1.4 Study quality is assessed and taken into account.
Well covered Not addressedAdequately addressed Not reportedPoorly addressed Not applicable
1.5 There are enough similarities between the studies selected to make combining them reasonable.
Well covered Not addressedAdequately addressed Not reportedPoorly addressed Not applicable
SECTION 2: OVERALL ASESSMENT OF THE STUDY2.1 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 clearly3.1 What types of study are
included in the review? (Highlight all that apply)
RCT CCT Cohort
Case-control Other3.2 How does this review help to
answer your key question?Summarise the main conclusion of the review and how it related to the relevant key question. Comment on any particular strengths or weaknesses of the review
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