A Systematic Review of Non-Drug Treatments for Dementia

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

Leeds Institute of Health Sciences July 2008

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

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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mailto:[email protected]

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



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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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:




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


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


26

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


27

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)


28

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


29

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


30

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 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


31

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


32

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


33

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


34

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.


35

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


36

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


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.


37

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


38

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


39

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


40

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


41

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,


42

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


43

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



with those with dementia. The reviews were of mixed quality, four

were assessed to be ++, three + and three -. With the exception of

Vink et al (2003) study design was not restricted to randomised

controlled trials.

The Vink et al (2003) review, rated ++, assessed the efficacy of

music therapy in the treatment of behavioural, social, cognitive and

emotional problems of older people with dementia. Five studies

were included in the review; all were randomised controlled trials.

Three compared music listening with a control intervention or no

intervention. The interventions included playing a patient’s

preferred music compared with classical music to reduce agitation;

playing preferred music during bath time to reduce occurrences of

aggressive behaviour; and group music activities including listening,

singing and playing compared with group reading sessions in

reducing wandering behaviour. All reported music listening more

effective than the control or no control. A further study compared

music group therapy with conversation sessions and music therapy

(intervention appears to be based primarily on singing) and the

affect on language functioning. It reported music therapy to be

more effective. The final study compared music therapy with puzzle

activities and general activities and again was reported to be more

effective in improving social and emotional functioning. However,

Vink et al assessed that none of the studies presented any of the

quantitative results in sufficient detail to justify the conclusions

drawn.

Sung and Chang (2005) provided a summary of the effects of

preferred music on agitated behaviours for older people with

dementia. The review included eight studies (two of which were

included in the Vink et al review). Whilst these two were randomised



controlled trials the other studies were of a variety of designs (case

study, case control, cross over with participant as own control)

characterised by small sample numbers (four studies n≤5). The

interventions included playing preferred music during the day and

playing preferred music during bath time. The findings from the

majority of included studies are positive in reducing agitated

behaviours. Sung and Chang concluded that music listening

interventions matched with personal preferences have positive

effects in reducing occurrence of some forms of agitated behaviours

in older people with dementia; but a number of methodological

limitations were apparent in the studies reviewed. The review, rated

++, provides a comprehensive description of methodology,

literature and findings; of particular strength is the concentration on

the use of preferred music only which adds consistency.

Sherratt et al (2004), rated +, reviewed 21 clinical studies looking at

the effects of a variety of music on the emotional and behavioural

responses in people with dementia. Whilst many of the studies

included in the review mirror those included in the Vink et al and

Sung and Chang reviews the study designs are not clearly

described. The interventions include group music activities and

listening to music. The majority of studies reported positive effects.

Music was found to be effective in decreasing a range of challenging

behaviours including aggression, agitation, wandering, repetitive

vocalizations and irritability. Music was also found to increase reality

orientation scores, time spent with one’s meal and social behaviour.

Whilst the review was comprehensive and discusses a number of

methodological issues (including, for example, observational data

collection methods) it does not address study design in relation to

assessment of quality.



Lou (2001) reviewed interventions that use music to decrease

agitated behaviour of the demented elderly person. All papers

identified for the review were included in one or more of the reviews

above. The interventions were all music listening (albeit some

described as background music). Lou concluded that music can be

useful as an intervention to help patients deal with agitated

behaviour problems and can increase patients’ quality of life but

that weakness and limitations in study design are considerable. The

review was rated -, because the search strategy is not clear in as

much as inclusion criteria is preferably with demented elderly and

no details are given of the numbers of papers identified in initial

screening. Limiting the search to two databases may have reduced

the papers identified.

The final review whose focus was solely music and music therapy,

Nugent (2002), examined the use of music and music therapy for

people who have Alzheimer’s disease and related disorders (ADRDs)

and display agitated behaviours. The review, rated -, supported the

premise that music and music therapy interventions reduce the

occurrence and frequency of agitated behaviours, that music

therapy may prevent extreme forms of agitation and that the

studies demonstrate that wandering and general restlessness is

reduced significantly. However, the author acknowledged that more

rigorous designs that include refined measuring tools and studies

that have larger sample sizes are required to gather more data. The

author’s conclusions were likely to overstate the effectiveness of the

interventions as all studies were given equal weight irrespective of

study quality and there is insufficient detail or assessment of the

quality of the papers.

Robinson et al (2006, 2007), rated ++, included one music therapy

study in their review of the clinical and cost effectiveness and

acceptability of non-pharmacological interventions to reduce


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.


48

Another general review (Livingston et al, 2005; rated +) of


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


49

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


50

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


51

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


52

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.


53

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 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,


54

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.


55

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.


56

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.


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


57

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.


58

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


59

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


60

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


61

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


62

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


63

for clarification about the precise nature of the intervention (Neal et

al, 2003).


64

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,


65

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/


66

http://www.medical-acupuncture.co.uk/

The British Complementary Medicine Association

(http://www.bcma.co.uk/).


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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http://www.bcma.co.uk/

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

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


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


69

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

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



70


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.


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


46 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=420&pageNumber=1



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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.


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

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

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

52 http://www.alzheimer-europe.org/pages/print_article.php?idart=C3448C7AFDFE



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http://www.alzheimer-europe.org/pages/print_article.php?idart=C3448C7AFDFE

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

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

http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=7E655C216B76


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.



56http://www.alzheimers.org.uk/factsheet/444

57 http://www.alz.org/living_with_alzheimers_repetition.asp


73

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.


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



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


74


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


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


75

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).



76

http://www.bacp.co.uk/

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


77

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



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



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


74 http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=CE9A3B723109




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http://www.alzheimer-europe.org/index.php?lm3=4815310DD10F&sh=CE9A3B723109




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


80

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

aggression or as a vehicle for communication. Music therapy

typically involves playing music for up to 30 minutes in a quiet room

with someone present for at least some of the time (to make sure

the person with dementia is comfortable and happy with the level of

sound)79. This could be tried at home. Carers could try joining the

person being cared for in listening to the music making it a shared

experience, an opportunity for both the carer and the person being

cared for to relax 80 and chat. The music can provide a focus for

conversation.

The Alzheimer’s Association suggest use of live music, tapes or CDs

as radio programs, interrupted by commercial breaks, can cause

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





81

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








82



http://www.alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200208&documentID=365

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


83

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





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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






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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




104 http://www.alzheimers.org.au/upload/CalmingEnvironment.pdf http://www.alzheimer-europe.org/index.php?

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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





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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 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.








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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


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



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



127 http://www.alzheimers.org.au/content.cfm?infopageid=4524#val


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

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



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

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


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:


tend to relate best to music they were familiar with when

younger





or irritation

Use sensory stimulation



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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.


136 http://www.alz.org/living_with_alzheimers_repetition.asp




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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:


tend to relate best to music they were familiar

with when younger



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



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.




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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




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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


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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




149 http://www.alz.org/living_with_alzheimers_aggression.asp


151 http://www.alzheimer-europe.org/index.php?lm3=6761D7E11104&sh=6C43BEDD7AAD


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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


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



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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.





may be available through local health care providers.



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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




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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




104


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.




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


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may be available through local health care providers.




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 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


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:




about the past.



a need to correct them make sure it is done



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


107

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



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.




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


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


108


validation therapy. In addition validation techniques to try at home

are detailed below


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.


can be confusing or frightening

Mirrors can be a source of hallucination; consider taking them

down or covering them up

Try validation techniques:




about the past.







109


a need to correct them make sure it is done



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



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 .


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



110


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.

















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


111


http://www.alz.org/living_with_alzheimers_wandering_behaviors.asp






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.



112


SECTION FOUR

Conclusions and Implications for Carers



they could try to access. The first part of the report focused on

three questions.


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.


The majority of interventions fell into the ‘might work’ category due

to inconclusive results (AAT, Aromatherapy, Behaviour

Management, Cognitive Stimulation, Environmental Manipulation,


113

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).


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).


114

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



115

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.


116

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


117

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.


118

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


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


119

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


Mood Neuropsychiatric Symptoms

Nutrition

Psychological Symptoms

Quality of Life / Well-being

Recall Sleep Social Behaviour

Wandering

Acupuncture


2 2

Aromatherapy 2 2


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


121

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


122

Table 2b . Animal Assisted Therapy (AAT): Key Characteristics of included systematic reviews (including at least one RCT). General Review Including AATAuthor,


the review

Research Question

Years covered

Search terms used

Databases searched

No of AAT

studies review

ed


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).


123

Table 3a. Aromatherapy: Key Characteristics of included systematic reviews (including at least one RCT). Author,


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.


124

http://lillytrials.com/

http://www.forestclinicaltrials.com/


http://clinicalstudies.info.nih.gov/


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


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


125

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


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


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


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.


126

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


reviewed


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


127

Table 5a. Cognitive Stimulation Therapy/Cognitive Rehabilitation/Cognitive Training: Key Characteristics of included systematic reviews (including at least one RCT). Author,

YearOverall



reviewed


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.


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


reviewed


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).


129

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


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




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


130

Author,Year


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


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






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








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




case study etc).


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).


133

Author,Year

Overall assessment

of the review

Research Question

Years covered Search terms used

Databases searched No of studies

reviewed


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).


134






Author,Year

Overall assessment

of the review


reviewed


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.


135

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

YearOverall


Research Question

Years covered Search terms used Databases searched No of light

studies reviewed




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





case study etc).


136

Table 9a. Massage and Touch: Key Characteristics of included systematic reviews (including at least one RCT). Author,

YearOverall



reviewed


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


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.


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


reviewed


Livingston

2005





recommendations about the use of

these interventions


Hand searched

three journal


2003

terms encompassing






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.





No dates given


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





case study etc).


138


139

Table10a. Music Therapy Reviews: Key Characteristics of included systematic reviews (including at least one RCT).

Author,Year

Overall assessmen

t of the review


reviewed


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


140




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

Author,Year


the review


reviewed


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


141

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

Author,Year


the review


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


142

Table 10b. Music Therapy: Key Characteristics of included systematic reviews (including at least one RCT). General reviews that included Music Therapy

Author,Year


the review


Search terms used


reviewed


Comments

Robinson 2006, 2007 (two papers report same

study)


acceptability of non-pharmacological interventions to

reduce wandering dementia

Search carried out up to and

including 31 March 2005


appendix


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


143

http://0-clinicalevidence.bmj.com.wam.leeds.ac.uk/ceweb/about/search_filters.jsp





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


the review


Search terms used


reviewed


Comments

Livingston2005

+ A systematic review of psychological approaches to the management of neuropsychiatric



recommendations about the use of these

interventions


Hand searched

three journal during 10

year period up to July

2003

terms encompassing

individual dementias and

interventions – no further details

given


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.


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


the review


Search terms used


reviewed


Comments

Cohen-Mansfield

2001


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


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).


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


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.

.


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


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.


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


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


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


psychological approaches to

the management

of neuropsychiatric symptoms of dementia

with the aim of making

evidence based

recommendations about the use of these interventions


Hand searched

three journal


2003

Terms encompassing






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.


149


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


Cohen-Mansfield

2001


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


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


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).


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



reviewed


Livingston

2005









terms encompassing





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




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





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.




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



reviewed


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.


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



reviewed


Livingston2005









terms encompassing



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




Verkaik 2005





September 2002 to

February 2003

Numerous terms included and

listed




SIGLE, DARE.

2 One RCTof low quality reports significantly lower self-reported

depression at post-test (but was higher than control at baseline).




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


Databases searched No of studies reviewed


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



(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


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


Robinson 2006 /

2007 (two papers on

same study)


acceptability of non-pharmacological

interventions to reduce wandering dementia

Search carried out up to and including 31 March 2005


appendix


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.


line with the findings.

Livingston2005









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





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


Verkaik 2005





September 2002 to

February 2003





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.







No dates given


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




case study etc).


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


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.


158

insufficient data to

recommend use.


159

Table 16a. Validation Therapy: Key Characteristics of included systematic reviews (including at least one RCT).

Author,Year

Overall assessmen

t of the review


reviewed


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



(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


line with the findings however, it should be noted that the authors report

a lack of clarity regarding whether participants have dementia.


160






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


reviewed


Livingston2005









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




Verkaik 2005





September 2002 to

February 2003





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.



Table 17. Characteristics of included systematic reviews that did not identify any studies for inclusion


161

Author,Year


the review

Research Question

Years covered

Search terms used


reviewed


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


162




Matrix 2a. Aggression Strategy

Organsiation

Activities to relieve boredom / distract

AAT Aromatherapy / massage or touch

Behaviour management

Cognitive stimulation

Counselling Environmental manipulation

Light 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






Light therapy



Reality orientation





163

http://www.alzheimer-europe.org/index.php?lm3=6761D7E11104&sh=6C43BEDD7AAD

Matrix 2c. Depression Strategy

Organsiation






Light therapy



Reality orientation




Matrix 2d. Hallucinations Strategy

Organsiation






Light therapy



Reality orientation



Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer EuropeReview (from section two)*

*Hallucinations not referred to specifically


164

Matrix 2e. Sleeplessness Strategy

Organsiation






Light therapy



Reality orientation



Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer EuropeReview (from section two)

Matrix 2f. Wandering Strategy

Organsiation






Light therapy



Reality orientation



Alzheimers Society (UK)Alzheimer’s Association (USA)Alzheimer’s AustraliaAlzheimer EuropeReview (from section two)


165

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http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Guo%20Y%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Easley%20KA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22O'Grady%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Wolf%20SL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

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


173

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/


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/



174




14. reminisce.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.


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.


175

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


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.


176

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


2. exp *creative arts therapy/

3. exp *exercise/

4. exp *games/

5. exp *psychodrama/

6. exp *phototherapy/

7. exp *vocational rehabilitation/




11. snoezelen$.tw.

12. dolls.tw.

13. or/1-12

14. exp *psychotherapy/


177

15. *reminiscence/



18. reminisce.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.


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:


178

[(dement* OR deliriu* OR alzheimer* OR creutzfeld* OR korsakoff*) in Title, Abstract or Keywords, from 2001 to 2007 in all products]


179

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.


1.3 The literature search is sufficiently rigorous to identify all the relevant studies.


1.4 Study quality is assessed and taken into account.


1.5 There are enough similarities between the studies selected to make combining them reasonable.


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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A Systematic Review of Non-Drug Treatments for Dementia

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