This article is an update on the overview in Advances in Psychiatric Treatment by Patel and colleagues which summarized the evidence base for psychosocial interventions in dementia. Since then there has been a large number of further studies examining the effectiveness of a wide range of non-pharmacological interventions. There has been great interest in exploring novel methods of enhancing the quality of life of people with dementia in recent years, particularly given the increased awareness of the significant harm being caused by the use of antipsychotics to manage the so-called behavioural and psychological symptoms of dementia (BPSD).
This article is an update on the overview in Advances in Psychiatric Treatment by Patel and colleagues which summarized the evidence base for psychosocial interventions in dementia.1 Since then there has been a large number of further studies examining the effectiveness of a wide range of non-pharmacological interventions. There has been great interest in exploring novel methods of enhancing the quality of life of people with dementia in recent years, particularly given the increased awareness of the significant harm being caused by the use of antipsychotics to manage the so-called behavioural and psychological symptoms of dementia (BPSD).
The discussion sections of the studies consistently draw attention to the need for greater standardization in measuring the effects of the various interventions. The ability to produce robust evidence has been a persistent issue in this area. Results have proved to be difficult to quantify reliably and ‘definitive evidence for the effectiveness of interventions has been lacking’.2 None the less, the results continue to show that psychosocial interventions are a fruitful area which should continue to be investigated as benefits have been demonstrated for both people with dementia and their carers. With increasing emphasis on supporting carers through the challenges of helping loved ones through the experience of dementia, the aim is to allow people to stay at home in familiar surroundings for as long as possible.
The availability of psychosocial interventions in dementia is gradually improving. As interest in ensuring people are diagnosed earlier and more accurately has grown, the provision of psychosocial interventions has generally lagged behind. While memory clinics have been established throughout the UK in each health locality since 2009, making the initial process of assessment and receiving diagnosis easier, the network of psychosocial support often remains more disorganized and harder to access. However, as the value of these interventions has become increasingly recognized, the quality and variety of psychosocial interventions has improved.
In the post-diagnosis period, psychosocial interventions play an important role in helping people adjust to their new diagnosis, helping to provide strategies to reduce the impact of symptoms of dementia, as well as enhancing remaining cognitive ability and level of functioning.3 Especially given the limited efficacy of current pharmacological treatments for dementia, there is a pressing need to employ the use of all possible treatments effectively. The key to effective psychosocial interventions is therefore to stimulate the remaining cognitive skills and level of functioning by promoting social participation and relationships, activating creative skills, while retaining meaningful occupations and interests.4
Part of the shift in attitude towards managing dementia involves adopting a person-centred approach, whereby the individual’s personhood is acknowledged to remain throughout the experience of dementia (see Chapter 24). Following from this, agitation and distress are considered to be forms of expressing unmet need rather than being meaningless ‘symptoms’ of dementia.
For the purposes of this chapter, a literature search has been completed for psychosocial interventions in dementia, with 285 studies being retrieved. A summary of the findings follows and the various interventions are grouped into creative, sensory, activity-based, psychological, carer-based and environmental categories.
Evidence for the effectiveness of art therapy in dementia has gradually increased since the late 1990s, with activities such as painting, making collages and cutting shapes frequently used. Lately there has been greater diversification in the forms of art therapy used and visual arts activities, where people with dementia appreciate works of art in museums, combined with producing art, have shown benefits in terms of expressing feelings, sharing stories through art, and improving people’s mental states. Four RCTs have reported ‘clinically relevant outcomes in treating behavioural, social, cognitive and emotional problems of dementia patients and their caregivers’.5
A systematic review, however, reported ‘very low’-quality evidence from 60 participants and found no significant difference in outcome measures between the art therapy group and the control group which carried out ‘simple calculation activities’ over 12 weeks.6
A museum staff education programme in the Netherlands, called ‘Unforgettable’, was evaluated and it was found that museum staff’s attitudes towards people with dementia improved significantly and helped towards participation of people with dementia in the programme.7
Reminiscence therapy is a popular tool used for people with dementia and encourages discussion of past events and life experiences in order to evoke personal memories and stimulate conversation.
A Cochrane systematic review of reminiscence therapy analysed evidence from 1,749 participants and included four large multicentre studies and several smaller studies of reasonable quality. Effects on quality of life, depression, communication, and cognition were found to be small and inconsistent. Individual approaches were associated with improved mood and cognition while group approaches were associated with improved communication.8 The impact on quality of life was most promising in care home settings. As in other areas, the diversity of approaches in utilizing reminiscence therapy has made direct comparison of studies difficult.
Therapies using music, dancing and singing have been incorporated into the schedules of many care homes and hospital wards caring for people with dementia, the basis for this being that recall memory is not an essential part of creativity and, in addition, gaining enjoyment from such activities is beneficial. The communal nature of these activities aims to improve communication and engagement between caregivers and patients. A systematic review of 12 studies demonstrated the efficacy of music therapy in reducing depression, agitation, and anxiety although it commented on the heterogeneity of interventions, methodological designs and evaluation tools.9
A meta-analysis incorporating three randomized controlled trials (RCTs) demonstrated sustained improvement in anxiety at three- and six-month follow-up in people with dementia who were anxious and had participated in a programme of music therapy combined with cognitive behavioural therapy.10 Significant improvements in agitation, aberrant motor behaviour and dysphoria were found in a RCT with 73 participants who had moderate dementia and were care home residents.11
Individualized music playlists, which residents in homes (for instance) can listen to via headphones, have become very popular and there is anecdotal evidence that they are effective at decreasing agitation and the use of medication (e.g. see www.playlistforlife.org.uk). In a systematic review using critical synthesis it was shown that playlists of this nature can have a beneficial effect even without a therapist, but the effects were not universally positive, suggesting the need for further research.12
Sleep disorders and disruptive behaviour overnight are commonly associated with dementia. The relatively new concept of the glymphatic system, which acts as a toxic metabolite clearance system in the central nervous system operating predominantly during sleep and inactive during wakefulness, has provided further clues as to the importance of sleep across all biological species. The abnormal deposition of beta-amyloid peptide throughout the brain has been identified as a key component in the pathogenesis of Alzheimer’s disease (AD). The fact that beta-amyloid is cleared by the glymphatic system suggests that abnormal sleep may be a risk factor in the development of AD rather than merely a consequence of it.13 The theory behind light therapy is that in our increasingly digitalized and artificially lit environments our natural circadian rhythms have been disturbed and require to be ‘reset’. In bright light therapy a person sits in front of a light box, which emits approximately thirty times more light than an average office light, in order to promote wakefulness during the day and better-quality sleep at night.
In one study with 17 participants, sleep disturbances were improved in patients with AD but not in other forms of dementia.14 A systematic review of 32 articles found that light therapy has shown mixed results in treating sleep and circadian disturbances in AD although generally the trend was for positive effects and no significant adverse effects.15
Phytotherapy adopts an empirical approach to the use of medicinal herbs, building on traditional knowledge. Aromatherapy is an important area within phytotherapy and uses essential oils extracted from various organs of aromatic plants that are applied either topically, including with massage, or administered via inhalation. The mechanism of action of aromatic plants is not currently clear. However, the olfactory nervous system, which transmits the aromatic stimulus to the hippocampus, limbic system and amygdala with consequent release of neuromediators, and the early presence of neurofibrillary tangles in the entorhinal cortex in AD suggest a putative link with olfaction.16 Indeed, early olfactory dysfunction has been associated with a number of neurodegenerative conditions. In one Taiwanese study with 186 participants, aroma-acupressure and aromatherapy were found to be significantly beneficial for agitation in dementia, with aroma-acupressure being superior to aromatherapy alone.17
Lack of sensory enrichment is a common feature in the lives of people with dementia as they often become passive recipients of care, with limited variation in daily routine, and have co-morbid visual and hearing impairment. The aim of multisensory stimulation is to provide greater diversity of sensory stimulation in a variety of different modalities, without the need for higher cognitive processing. Multisensory rooms have been adopted in settings such as care homes and are typically soothing spaces with relaxing music and lights, and interesting textures to touch. Increased alertness, reduced apathy, positive effects on mood and increased social engagement have been reported following the use of such spaces.18
SENSE-Cog is a European, multicentre RCT currently being undertaken with 354 participants who have dementia and visual or hearing impairment which is examining whether a home-based multipart sensory intervention is effective in improving quality of life and other key outcomes (www.sense-cog.eu).
Animals bring innate pleasure to humans from a very early age and the literature has frequently reported benefits for people with dementia of contact with animals of various sorts. In a study with 19 people with moderate to severe dementia in Germany, significantly increased pleasure and social interaction were reported following a six-month period of weekly group sessions with dogs, compared to a control group.19 However a systematic review which included six RCTs and four quasi-experimental studies found evidence (albeit of very low certainty) that dog-assisted therapy had no effect on daily life activities, mood, agitation, quality of life or cognitive impairment. One small study in this systematic review found an apparent beneficial effect on apathy.20
The benefits of exercise appear to be intuitive and there is well-established evidence for the reduction of vascular risk factors generally. Evidence has also been found for increase in hippocampal volume, improved spatial memory, as well as the induction of brain neurotrophic factors in multiple animal studies.
There is conflicting evidence from various recent systematic reviews, however, on the effects of exercise on progression of dementia. The National Institute for Health Research commissioned the Dementia and Physical Activity trial to inform this debate and found that moderate to high intensity aerobic and strength exercise training programmes did not slow the rate of cognitive decline in people with mild to moderate dementia. Improvements in physical fitness were noted but not in any other clinical outcomes.21 A two-year prospective study is currently being conducted to examine whether long-term exercise programmes prevent the onset of dementia in people at risk over the age of 50.22
A meta-analysis including 10 trials and 682 participants found benefits in overall sense of wellbeing for walking programs compared to control groups.23 A systematic review of 197 studies indicated that medium-to longer-term moderate-to high-intensity exercise improves global physical and cognitive functions as well as skills in activities of daily living.24
Participating in valued activities, whether for work, leisure or family, is an important aspect of self-identity.25 As cognitive function declines in dementia, abilities developed over a lifetime also decline contributing to a sense of loss of self. Ensuring that people with dementia continue to find meaning and purpose in their daily life and feel empowered is the key component of individual activity programmes. Depending on the interests and current abilities of the individual, the activity or occupation would vary. A number of studies are currently being undertaken to evaluate the effectiveness of such activities, but no further evidence appears to be available since the previous review, which found weak evidence but undeniable signs of a sense of connection, well-being, belonging, self-autonomy and identity.1
The use of dolls for people with dementia appears to provide a sense of security and familiarity. An increase in displays of pleasure was found at week three of a RCT involving 35 residents of a care home in Australia. There appeared to be no improvement in anxiety, agitation or aggression compared to the control group.26 Care home staff’s perceived benefits for residents of the doll therapy, however, were of emotional comfort, a calming effect and the provision of a purposeful activity. A reduction in BPSD was found on relevant rating scales as well as in caregiver-related stress in a care home for residents living with severe dementia, suggesting that this is a promising approach.27
With improvements in technology there have been advances in the dolls used. PARO robotic seals, for instance, are advanced, interactive, therapeutic animal dolls designed to stimulate people with dementia. Reductions in agitation and medication use have been demonstrated in care home residents, although use of a plush toy had similar effects while providing marginally greater value for money.28 Considerable variation in responses to the PARO dolls have also been found.29