A Systematic Review of Non-Drug Treatments for Dementia

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A Systematic Review of Non-Drug Treatments for Dementia

  1. 1. Leeds Institute of Health Sciences FACULTY OF MEDICINE AND HEALTH A Systematic Review of Non-Drug Treatments for Dementia Claire Hulme Judy Wright Tom Crocker Yemi Oluboyede Allan House July 2008 Charles Thackrah Building University of Leeds 101 Clarendon Road Leeds, United Kingdom LS2 9LJ www.leeds.ac.uk/lihs
  2. 2. CONTENTS Page EXECUTIVE SUMMARY 4 ACKNOWLEDGEMENT 11 SECTION ONE 12 Background 12 Aim 15 Methodology 16 Literature Search 16 Quality Appraisal 18 Dementia Organisation 19 SECTION TWO 20 Review of Effectiveness 20 Interventions 20 Symptoms 21 Interventions and Symptoms 22 Overview of Papers 23 Interventions 23 Acupuncture 23 Animal Assisted Therapy 24 Aromatherapy 27 Behaviour Management 29 Cognitive Stimulation Therapy/Cognitive Training 31 Counselling 35 Environmental Manipulation 35 Light Therapy 37 Massage/Touch 39 Music / Music Therapy 41 Physical Activity/Exercise 47 Reality Orientation 50 Reminiscence Therapy 51 Snoezelen/Multi-sensory Stimulation 53 TENS 57 Validation Therapy 58 SECTION THREE 61 Introduction 61 Interventions 62 Acupuncture 62 Animal Assisted Therapy 63 Aromatherapy and Massage 65 Behaviour Management 70 Cognitive Stimulation Therapy/Cognitive Training 71 Counselling 72 Environmental Manipulation (including lighting) 72 Music / Music Therapy 76 Physical Activity/Exercise 79 Leeds Institute of Health Sciences July 2008 2
  3. 3. Reality Orientation 83 Reminiscence Therapy 84 Snoezelen/Multi-sensory Stimulation 85 TENS 86 Validation Therapy 87 Symptoms or Behaviour 89 Creating a Relaxing Environment 90 Activities 92 Aggression 95 Agitation or Anxiety 97 Depression 100 Hallucinations 103 Sleeplessness 105 Wandering 106 SECTION FOUR 108 Conclusion and Implications for Carers 108 Implications for Future Research 111 Implications for Service providers and Commissioners 113 REFERENCES References (studies/papers included in review) 157 References (report references) 160 APPENDIX ONE (search strategies) 164 APPENDIX TWO (data extraction template) 171 TABLES, MATRICES, BOXES Table 1: Acupuncture 116 Table 2: Animal Assisted Therapy 117 Table 3: Aromatherapy 119 Table 4: Behaviour Management 121 Table 5: Cognitive Stimulation Therapy/Cognitive Training 123 Table 6: Counselling 126 Table 7: Environmental Manipulation 127 Table 8: Light Therapy 129 Table 9: Massage/Touch 132 Table 10: Music /Music Therapy 134 Table 11: Physical Activity/Exercise 140 Table 12: Reality Orientation 144 Table 13: Reminiscence Therapy 145 Table 14: Snoezelen/Multi-sensory Stimulation 147 Table 15: TENS 150 Table 16: Validation Therapy 151 Table 17: Systematic reviews that did not identify 153 any studies for inclusion Matrix 1: Interventions and Symptoms Evidence Assessment 114 Matrix 2: Interventions, Behaviour/Symptoms, Oganisation 154 Box 1: Reasons for Exclusion from the Review 18 Box 2: Types of Symptoms 21 Box 3: Interventions and Symptoms 22 Leeds Institute of Health Sciences July 2008 3
  4. 4. 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 Leeds Institute of Health Sciences July 2008 4
  5. 5. 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 Effectiveness Leeds Institute of Health Sciences July 2008 5
  6. 6. 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. 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 Leeds Institute of Health Sciences July 2008 6
  7. 7. 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. General strategies: • To reduce behavioural and psychological symptoms of dementia create a relaxing environment paying attention to noise levels, lighting, music, 3 http://www.alzheimer-europe.org/index.php?lm3=78610D3AB11E&sh=E710167106DE Leeds Institute of Health Sciences July 2008 7
  8. 8. other sensory stimulants like massage and touch. Pets may also have a calming effect • In some cases difficult behaviours can be headed off or coped with by using an activity which provides a distraction from the behaviour or stops boredom. Carers might try music activities, activities with pets such as walking or petting the dog, sensory stimulation using massage or other touch therapies or activities that involve reminiscing. Physical activities can help use up spare energy, and provide a sociable activity giving routine and structure to the day The following are activities or techniques that carers might like to try access locally. At the end of each suggestion the behaviour for which it might be beneficial is given in brackets. • Training course for carers: • Behaviour management techniques. Carers can also ask for an assessment of key factors that may improve challenging behaviour in those they are caring for (aggression, agitation, anxiety, depression, wandering) • Techniques of validation therapy (aggression, depression, hallucinations) o Interventions for the person with dementia: • Animal Assisted Therapy (aggression, agitation, anxiety, depression) • Bright light therapy (agitation, sleeplessness) • Music therapy (aggression, agitation, anxiety, depression, hallucinations, wandering) • Multi-sensory stimulation (aggression, depression, wandering) • Reminiscence therapy (agitation, anxiety, depression, hallucinations) • Counselling or cognitive behaviour therapy (depression) Leeds Institute of Health Sciences July 2008 8
  9. 9. • Cognitive stimulation therapy (depression) • Reality orientation (depression) Techniques or strategies that carers may try at home include: • Having a pet in the home to encourage relaxation, to provide a distraction, provide comfort, stimulate conversation and provide the opportunity for exercise and social contact • Use aromas (for example lavender oil) to create a calm environment • Try massage or touch to soothe, to distract, encourage interaction, provide reassurance, encourage eating, or reduce wandering • Create a calming environment by removing competing noises, ensuring lighting is adequate, using nightlights for reassurance • Try using music as the focus of activity, sharing music together, encouraging singing clapping or even dancing • Use background music to help create a calming environment • Try different forms of physical activity. This can be formal classes such as tai chi or informal activities like housework • Try activities that involve reminiscing e.g. looking at old photos or old books or making a family scrapbook Conclusions Overall the studies included in the reviews were characterised by weak study designs and small sample sizes. Indeed three reviews were unable to identify any studies of sufficient quality to assess. Many of the reviews included single person case studies or studies of less than five people. Whilst it is not possible to generalise about the effectiveness of different interventions many pointed to potential benefits from the intervention being assessed. Leeds Institute of Health Sciences July 2008 9
  10. 10. Many of the studies included were based in community residential settings (for example, in nursing homes). Given the increasing number of people now caring for people with dementia in their own home there is a clear need to ensure that research is transferable to this setting. Indeed, the International Psychogeriatric Association (IPA) note that further research is need to explore the relationship of behavioural and psychological symptoms of dementia to the environments in which they occur (IPA, 2002, p7) Taken together, whilst the volume of studies in this area is encouraging the review points to the need for large, well designed, randomised controlled studies rather than the seemingly piecemeal approach taken at present. The suggestions or recommendations made by dementia organisations appear to be based on existing research evidence together with suggestions from carers themselves about what works for them. The focus of these suggestions lies in behaviour and psychological symptoms. This is unsurprising given that virtually all patients with dementia will develop changes in behaviour as the disease progresses (Rayner et al, 2006, p647). Whilst the suggested strategies appear to be general, rather than specific across many behaviours the consensus opinion is that the incidence of distress can be ameliorated by a calming environment, structured activities and redirection or distraction (Lavretsky and Nguyen, 2006). Whilst carers can apply some of the 16 interventions in the home setting at little or no cost to health or social care services (for example, playing favourite music), others are likely to require training (for example in hand massage) or instruction (for example, in appropriate exercise routines). Both service providers and commissioners should explore current and future provision of more structured group activities for people with dementia in line with the evidence presented; in particular the provision of group music Leeds Institute of Health Sciences July 2008 10
  11. 11. therapy and group exercise activities that meet the needs of both the person with dementia and their carer. ACKNOWLEDGEMENT "This work was made possible by a generous bequest from the estate of Gilda Massari, whose wish was to fund research that produced practical benefit for the carers of people with Alzheimer's disease and related conditions. A version for carers is available from The Dementia Services Development Centre, University of Stirling, dementia@stirling.ac.uk " Leeds Institute of Health Sciences July 2008 11
  12. 12. SECTION ONE Background Dementia is used to describe a collection of symptoms, including a decline in memory, reasoning and communication skills, and a gradual loss of skills needed to carry out daily activities (Knapp et al, 2007); it is a non-reversible deterioration in memory, executive function and personality (Warner et al, 2006). In the UK it is estimated that there are 700,000 people with dementia representing around one person in every 88 (1.1%) of the entire population (Knapp et al, 2007). This figure is set to increase to over 940,110 by 2021 (Knapp et al, 2007). Dementia is most common in older people; in the UK one in five people over the age of 80 years and one in 20 over the age of 65 years has a form of dementia (Knapp et al, 2007). Typically dementia is reported under four categories: Alzheimer’s disease, vascular dementia, Lewy body dementia and frontal temporal dementia. All are characterised by problems with cognitive functioning and those with dementia are likely to experience behavioural and psychological symptoms (Warner et al, 2006). Alzhiemer’s disease is the most prevalent type of dementia; in the UK Alzheimer’s accounts for around 6 out of 10 cases of dementia4 . It is a progressive and eventually fatal disease (Yuhas et al, 2006, p35) of unknown etiology with characteristic neuropathological and neurochemical features5 . It is characterised by an insidious onset and slow deterioration and involves impairments of speech, motor, personality and executive function (Warner et al, 2006). Alzheimer’s typically affects older people but can begin in younger 4 http://www.patient.co.uk/showdoc/23068719/ 5 http://www.who.int/classifications/apps/icd/icd10online/ Leeds Institute of Health Sciences July 2008 12
  13. 13. individuals. Whilst the cause of Alzheimer’s is unknown risks factor include family history of the disease and advanced age (Griffiths and Rooney, 2006). In the early stages of Alzheimer’s there are signs of memory loss that may include small behaviour changes, forgetting things or repeating things more than usual. In the next stage cognitive impairment becomes more evident and symptoms more disruptive (individuals struggle with activities of daily living and may neglect their personal appearance). In this stage individuals may need reminders to carry out activities of daily living and might have difficulty in recognising familiar places or people (Knapp et al, 2007). Over time, and in the final stages, there is increased dependency on others due to severe impairment of intellectual abilities. As physical functioning deteriorates individuals may become incontinent, unable to feed themselves and bedridden; speech is problematic and the individual may no longer engage in conversation. Eventually total care will be needed (Yuhas et al, 2006). Vascular dementia, the second most common type of dementia in the UK, results from infarction of the brain due to vascular 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 symptoms may appear at any stage of the illness. Behaviours that may be present include nocturnal confusion and wandering (Yuhas et al 2006). Progression may be slowed through control of underlying risk factors such as blood pressure (Knapp et al, 2007). 6 http://www.who.int/classifications/apps/icd/icd10online/ Leeds Institute of Health Sciences July 2008 13
  14. 14. Lewy body dementia is a progressive dementia identified by abnormal structures in the brain cells called Lewy bodies (Yuhas et al 2006). Tiny spherical protein deposits develop inside the nerve cells in the brain interrupting the brain’s normal functioning, affecting memory, concentration and language (Knapp et al, 2007). This type of dementia is characterised by fluctuation of symptoms, the presence of early and prominent visual hallucinations and Parkinsonian symptoms (slow movement, bending slightly forward and shuffling when walking) (Yuhas et al 2006). Progression is more rapid than Alzheimer’s disease but short term memory is usually good. Those with this type of dementia can show marked fluctuations in alertness or cognition from hour to hour or week to week – characterised by confusion during which it is difficult to concentrate and complete tasks. Likely psychotic symptoms include paranoia, delusions and hallucinations which can be disruptive. People with Lewy bodies dementia are at risk of falls because of lack of an effective righting reflex and may experience restless leg syndrome which can interfere with sleep (Yuhas et al 2006). Frontal temporal dementia is typically exhibited in those with a group of rare neurological disorders affecting the frontal and anterior temporal lobes of the brain; these include Pick’s disease, frontal lobe degeneration, and dementia associated with motor neuron disease (Yuhas et al 2006). It is likely to affect people under 65 and is characterised by gradual onset of changes in personality, social behaviour and language, dependent on whether damage has occurred in the left side (language) or right side (behaviour) of the front of the brain (Yuhas et al 2006). The later stages are characterised by difficulties with speech and language, memory loss and oral fixations. Behavioural and psychological disturbances are common (Yuhas et al 2006). Leeds Institute of Health Sciences July 2008 14
  15. 15. In the UK there is increasing focus on dementia. A recent report from the House of Commons Committee of Public Accounts acknowledged that dementia, despite its financial and human impact, has not received the same priority status as other diseases. It is estimated that in England alone late- onset dementia costs some £14.3 billion per year. This estimate includes the cost of care home accommodation (£5.72 billion, 40%) and an estimated saving to the taxpayer of £5.29 billion (37%) from the contribution made by informal carers (the NHS and social care make up the remainder; £1.14 billion 8% and £2.15 billion 15% respectively)7 . The House of Commons report highlights the heavy burden carried by those caring for relatives with dementia at home. Indeed informal carers8 deliver most of the care to people with dementia in the UK and many are elderly and frail themselves9 . A National Dementia Strategy is planned for 200810 . Aim The aim of this report is to help informal carers who want ideas about non- drug approaches for dementia, that they might try or that they could try to access. Using a two part process, initially a systematic review was carried out in order to addresses the following questions: • What non-drug treatments work and what do they work for? • What non-drug treatments might work and what for? • What non-drug treatments do not work? 7 http://www.publications.parliament.uk/pa/cm200708/cmselect/cmpubacc/228/228.pdf 8 Informal carers are people who look after a relative or friend who needs support because of age, physical or learning disability or illness, including mental illness. 9 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=546 10 http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Olderpeoplesservices/DH_077211 Leeds Institute of Health Sciences July 2008 15
  16. 16. The second part of the process searched the websites of four national (UK, USA and Australia) and international (Europe) dementia organisations to identify recommendations or suggestions for non-drug approaches for dementia. In each case the strategies identified from the websites were aligned with the non-drug treatments identified in the systematic review to produce a series of suggestions or ideas for informal carers about non-drug approaches for dementia, that they might try or access. Methodology The systematic review has been carried out by a team from the Institute of Health Sciences, University of Leeds. Literature Search The search strategy was developed by the review team at the University of Leeds. Literature searches of electronic databases and websites were then carried out. Comprehensive searches of the following databases were carried out on 7th November 2007: • AMED (via OVID host) • CINAHL (via OVID host) • EMBASE (via OVID host) • MEDLINE (via OVID host) • PSYCINFO (via OVID host) • Cochrane Library of Systematic Reviews (via Wiley host) • DARE (via Wiley host) The search strategies used can be found in Appendix 1. Inclusion Criteria 1. Systematic reviews only (not reviews) including at least one randomised controlled trial of a non-drug intervention 2. English language Leeds Institute of Health Sciences July 2008 16
  17. 17. 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. Leeds Institute of Health Sciences July 2008 17
  18. 18. Box 1: Reasons for Exclusion from the Review Not systematic reviews only (not reviews) including at least one randomised controlled trial of a non-drug intervention 57 Not English language 4 The 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 2 Not received in time to be included 2 Précis of a review only 1 Withdrawn 1 Background only 6 Total 79 Quality Appraisal Data relating to the scope of this review was extracted from each study using the National Institute of Clinical Excellence (NICE) data extraction template (NICE 2006). Methodological checklists (NICE 2006) were applied to each study to determine the quality of each study. The checklist states that in a well-conducted systematic review:  The study addresses an appropriate and clearly focussed question  A description of the methodology used is included  The literature search is sufficiently rigorous to identify all relevant studies  Study quality is assessed and taken into account  There are enough similarities between the studies selected to make combining them reasonable (NICE 2006, p112) Each study was given a rating of ++ (high) + or – (low). Studies assessed ++ are those in which all or most of the above criteria on the checklist are fulfilled. Where the criteria are not fulfilled the conclusions the review comes to are thought very unlikely to alter. For those assessed + some of the above criteria is fulfilled. Those not fulfilled or adequately described are thought unlikely to alter the review’s conclusions. A rating of – is applied where few Leeds Institute of Health Sciences July 2008 18
  19. 19. or none of the above criteria are fulfilled. Had they been fulfilled the review’s conclusions are likely or very likely to alter. Studies were categorised according to intervention type. Within each of these categories evidence is provided using a narrative synthesis, supported by evidence tables, drawing out the key features of each study. Evidence is provided in a hierarchy with higher quality studies ranked first in the evidence tables. Dementia Organisations Criteria for inclusion of dementia organisation was that they be national/international organisations and that website was freely available, written in English and includes fact sheets, tips or suggestions for informal carers. Search of the websites was carried out by intervention type (as identified in the systematic review) and by behaviour/symptom type (again as identified in the systematic review). Where the web pages included links to, or referred to, additional pages or other sites these were also followed. Using content analysis the recommendations were grouped by intervention type and behaviour/symptom type. The search was stopped at four dementia organisations as saturation was achieved. The organisations and website address are shown below. Four national/international dementia websites were included: • Alzheimer’s Society (UK) http://www.alzheimers.org.uk/site/ • Alzheimer’s Association (USA) http://www.alz.org/index.asp • Alzheimer’s Australia (Australia) http://www.alzheimers.org.au/index.cfm • Alzheimer Europe http://www.alzheimer-europe.org/ Leeds Institute of Health Sciences July 2008 19
  20. 20. SECTION TWO Review of Effectiveness The review identified 35 papers representing 33 studies (2 papers reported on the same studies) which met the inclusion criteria. In addressing the review questions: • What non-drug treatments work and what do they work for? • What non-drug treatments might work and what for? • What non-drug treatments do not work? Interventions The studies were grouped by intervention into 16 key areas: • Acupuncture • Animal Assisted Therapy • Aromatherapy • Behaviour Management • Cognitive Stimulation Therapy/Cognitive Training • Counselling • Environmental Manipulation • Light Therapy • Massage/Touch • Music/Music Therapy • Physical Activity/Exercise • Reality Orientation • Reminiscence Therapy • Snoezelen/Multi-sensory Stimulation • TENS • Validation Therapy Leeds Institute of Health Sciences July 2008 20
  21. 21. Symptoms The symptoms of dementia addressed in the papers include in the review were varied and ranged from the specific to the general. In order to make sense of these, each has been grouped into one of the three main types symptoms typically displayed by people with dementia (see box 2 below). The three main types of symptom are: loss of cognitive function, impairment of the ability to perform activities of daily living (ADLs) and abnormal behaviour11 . Loss of cognitive function often manifests itself in memory loss whilst impaired functional ability can affect, for example, a person’s ability to get dressed or brush their teeth. Abnormal behaviour covers both behavioural and psychological symptoms. Indeed the term behavioural and psychological symptoms (BPSD) is used to describe the non-cognitive manifestation of dementia (Bianchetti and Trabucchi, 2004). The groupings used by Bianchetti and Trabucchi have been used inform the classification of symptoms. Box 2: Types of Symptoms Cognitive Ability Ability to perform activities of daily living Behavioural and psychological symptoms Cognitive Function Communication Learning Memory Recall Functional Ability Quality of Life/Well- being Aggression Agitation Anxiety Apathy Behaviour Depression Emotional and Behavioural Responses Inappropriate Behaviour Mood Neuropsychiatric Symptoms Nutrition Psychological Symptoms Sleep Social Behaviour Wandering 11 http://www.searo.who.int/en/Section1174/Section1199/Section1567/Section1823_8057.htm Leeds Institute of Health Sciences July 2008 21
  22. 22. Interventions and Symptoms Matrix 1 on page 114 cross references the individual symptoms to intervention type to give a summary of evidence of effectiveness. Box 3 (below) provides a précis of the type of symptom and intervention. For example, Cognitive Stimulation Therapy or Training was used to address symptoms in all three categories whereas Animal Assisted Therapy was used only to address behavioural and psychological symptoms. Box 3: Interventions and Smptoms Cognitive Ability Ability to perform activities of daily living Behavioural and psychological symptoms Cognitive Stimulation Therapy/Cognitive Training Counselling Light Therapy Music/Music Therapy Physical Activity/Exercise Reality Orientation Reminiscence Therapy Snoezelen/Multi- sensory Stimulation TENS Validation Therapy Cognitive Stimulation Therapy/Cognitive Training Physical Activity/Exercise Reality Orientation Snoezelen/Multi- sensory Stimulation Animal Assisted Therapy Aromatherapy Behaviour Management Cognitive Stimulation Therapy/Cognitive Training Environmental Manipulation Light Therapy Massage/Touch Music/Music Therapy Physical Activity/Exercise Reality Orientation Reminiscence Therapy Snoezelen/Multi- sensory Stimulation TENS Validation Therapy Leeds Institute of Health Sciences July 2008 22
  23. 23. Overview of Papers The majority of papers identified in this review were concerned with dementia in a generic sense in as much as they did not identify one type of dementia or a specific stage of dementia. The focus of the six papers that were more specific were Alzheimer’s disease (Clare & Woods, 2003; Grandmaison & Simar, 2003; Penrose, 2005; Sitzer et al, 2006), vascular dementia (Clare & Woods, 2003: Peng et al, 2007) and milder dementia or early stage dementia (Clare & Woods, 2003; Bates et al, 2004). The samples within the studies typically consisted of older people. Overall the research studies presented within the reviews identified were characterised by weak study designs with small sample numbers. This meant that three of the reviews included (Hermans et al, 2007; Peng et al, 2007; Price et al, 2001) presented their objectives, search strategies and selection criteria but did not find any suitable studies for inclusion in their reviews. The study inclusion criteria for Hermans et al (2007) and Peng et al (2007) included only randomised controlled trials; Price et al (2001) also included controlled trials and interrupted time series. Details of these studies are presented in tables 1 and 17. Reference is also made to them where appropriate in the text. Interventions Acupuncture Traditional acupuncture is used to treat a wide range of illnesses.12 The treatment involves fine needles being inserted through the skin and briefly left in position. The number of needles varies but may be only two or three13 . Only one review was identified that attempted to explore the use of 12 http://www.acupuncture.org.uk/content/AboutAcupuncture/acupuncture.html 13 http://www.medical-acupuncture.co.uk/patients/ Leeds Institute of Health Sciences July 2008 23
  24. 24. acupuncture (Peng et al, 2007). A summary of the key characteristics of the review are given in table 1, p116. Peng et al aimed to assess the efficacy and possible adverse effects of acupuncture therapy for treating vascular dementia. To be included in the review studies should be randomised controlled trials, participants with a diagnosis of vascular dementia according to accepted criteria, and research comparing any type of acupuncture therapy with placebo or no intervention. The review did not identify any studies that met the criteria and thus has not been given a quality rating. Summary No evidence was identified to support the use of acupuncture for those with vascular dementia. Animal Assisted Therapy (AAT) Formally AAT most commonly involves interaction between a client and a trained animal, facilitated by a human handler, with a therapeutic goal such as providing relaxation or pleasure, or incorporating activities in physical therapy or rehabilitation (Filan & Llewellyn-Jones, 2006, p598). Thus, AAT may simply be to focus on the animal for a specified time (for example grooming a dog or petting it). This can promote conversation or physical activity or promote conversation about previous pets which increases over time14 . Indeed studies in the 1980s indicated that pets promoted dialogue among family members and contributed to well-being (Wilson & Turner, 1998). However, it is reported that the benefits of therapy pets vary a lot by the individual15 . 14 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1 15 http://www.dogplay.com/Activities/Therapy/tFAQ.html#Define1 Leeds Institute of Health Sciences July 2008 24
  25. 25. Two reviews (Filan & Lllewellyn-Jones, 2006; Cohen-Mansfield, 2001) considered the use of animals as part of the therapeutic process for those with dementia with the aim of reducing agitation and/or aggression, promoting social behaviour and improving nutrition. A summary of the key characteristic of the reviews are provided in table 2, p117-118. Whilst many of the studies included in the reviews consider AAT in terms of a trained animal and therapist others consider the presence of a dog or cat in the home (both in a residential and private setting) either full time or for short periods of time to reduce agitation and/or aggression and promote social behaviour. Indeed it has been suggested that the presence of an animal can provide a sense of meaning, diversion and serendipity; that companion animals provide unconditional positive regard in stages of Alzheimer’s disease where normal avenues of communication fail (Baum & McCabe, 2003). They go on to suggest that caregivers might also benefit from the stress reduction that results from petting a familiar companion animal (p44). The first review of 11 studies (Filan and Lllewellyn-Jones, 2006), which was assessed as +, appraised studies that have investigated whether AAT has a measurable beneficial effect for people with dementia and specifically upon behavioural and psychological symptoms of dementia. The study interventions included ‘pet visits’, the introduction of a resident dog and introduction of aquaria. Six studies within the review reported on the impact on anxiety and aggression (of either the introduction of a dog or cat at specified periods or a ‘resident’ dog); all report at least one significant, positive result. Four assess the impact on social behaviour (of either the introduction of a dog or cat at specified periods or a ‘resident’ dog); all report positive results. One study reported on the impact on nutrition and reports a significant increase in food intake and monthly resident weight when a fish tank is introduced in the Leeds Institute of Health Sciences July 2008 25
  26. 26. dining area of a nursing home. The review concludes that AAT appears to offer promise as a psychosocial intervention for people with dementia. However, the optimal frequencies and duration of AAT sessions, as well as the optimal format of such sessions, need systematic study. The review is hampered by lack of detail in the study design; some aspects of study design are not clear, for example whether samples were randomised. The small sample sizes and selection criteria are likely to over estimate the results. The authors point to several limitations in the studies reviewed; these include potential bias when participants have a prior history of positive interaction with animals, small sample sizes, and unclear duration of impact. The second review, Cohen-Mansfield (2001) was rated as -. The review appraised the impact of non-pharmacological interventions on inappropriate behaviours in dementia and identified three AAT studies. All three studies reported positive results (the interventions are: certified dog therapy for two 30 minute sessions, companion animals and a pet dog for one hour a day for five days). However, in the latter study only 22% of participants had been diagnosed with dementia. There is little quality assessment within the review in respect of the type of study design (RCT, case study etc) which means that all the studies included appear to be given equal weight. Methodological issues are presented within the discussion section, these relate to diverse measurement methods, criteria for success, screening procedures, control procedures and treatment of failures. Summary The majority of studies in the reviews conformed to the definition of AAT in as much as they included a trained animal (usually a dog) and trained handler rather than evaluating the impact of having a pet per se. Leeds Institute of Health Sciences July 2008 26
  27. 27. The studies that explored use of AAT (typically the introduction of a dog or cat at specified periods or a ‘resident’ dog) report positive results in behaviour and psychological symptoms (reducing agitation and aggression, improving social behaviours including more interaction and longer duration of smiles). However, as noted by Filan and Lllewellyn-Jones, the studies were characterised by small sample numbers, include potential bias when participants have a prior history of positive interaction with animals and duration of any improvement is unclear. The lack of detail in reporting the studies (even where it is clear there is a control group, it is unclear whether participants have been randomly assigned to the groups) means that the evidence is not robust. The conclusion drawn is that AAT might work to reduce aggression and agitation, improve social behaviour and improve nutrition. However, further research that addresses the above limitations is required in order to provide evidence that it does work. Aromatherapy Aromatherapy is the systematic use of essential oils in holistic treatments with the aim to improve physical and emotional well-being. It is reported that essential oils, extracted from plants, can be utilised to improve health and prevent disease and are applied in a variety of ways16 . Essential oils may be incorporated through massage, by adding a few drops to baths or by inhalation (for example, by way of a diffuser). Three systematic reviews (Thorgrimsen et al, 2003, 2006; Robinson et al, 2006, 2007; Diamond et al, 2003) explored the effectiveness of aromatherapy in reducing behavioural and psychological symptoms (agitation, neuropsychiatric symptoms and wandering). A summary of the key characteristic of the reviews are provided in table 3, p119-120. 16 http://www.aromatherapycouncil.co.uk/index_files/Page390.htm Leeds Institute of Health Sciences July 2008 27
  28. 28. Thorgrimsen et al (2003, 2006), in their review, rated ++, appraised two randomised controlled trials. The first compared use of lemon balm (Melissa) plus a base lotion against sunflower oil both applied to the arms and face twice daily over four weeks. Additional analyses of the study data revealed a statistically significant treatment effect in favour of the aromatherapy intervention on measures of agitation and neuropsychiatric symptoms, but there were several methodological difficulties with the study. The second trial in the review compared the effects of lavender applied through massage, lavender applied through a diffuser accompanied by conversation and conversation alone. No statistically significant difference was found between groups. Similarly Robinson et al (2006, 2007) in their review (again rated ++) reported on two randomised controlled trials (the first is the same lemon balm trial reviewed by Thorgrimsen et al, the second compares lemon balm and lavender with neutral control oil). Overall the review reported no robust evidence of the efficacy and the evidence was deemed to be of low quality. The first randomised controlled trial reported that participants receiving essential oils showed less wandering behaviour (marginal statistical significance); the second found no difference between groups. Diamond et al (2003) (rated -) included seven aromatherapy studies within their review. The review included both the randomised controlled trials in Robinson et al. Diamond et al reported that aromatherapy may have moderately beneficial effects; but that better controlled studies with larger sample sizes are needed to evaluate the effect of aromatherapy on the affect and behaviour of persons with dementia. The review was rated – because study quality was not assessed within the review, all the studies included were given equal weight. Leeds Institute of Health Sciences July 2008 28
  29. 29. Summary There is some evidence that aromatherapy might reduce agitation, neuropsychiatric symptoms and wandering. However, relatively few studies were identified within the reviews and the evidence that was presented was not robust. The randomised controlled trials within the reviews produced conflicting results in terms of their effectiveness. These conflicting results may be a result of differences between interventions (for example, the oils use). All reviews suggested that better controlled studies with larger sample sizes are needed to evaluate the effect of aromatherapy. Behaviour Management Behaviour management covers a wide spectrum of techniques to address challenging behaviour. Some of these are addressed in separate sections within this review (for example environmental manipulation to manage wandering) Three studies were found that included behaviour management studies (Robinson et al, 2006, 2007; Verkaik et al, 2005; Livingston et al 2005). Of interest in the reviews was the effect on wandering, depression, aggression, apathy and neuropsychiatric symptoms. The interventions under the behaviour management umbrella included social skills training, problem solving and behavioural reinforcement. A summary of the key characteristic of the reviews are provided in table 4, p121-122. Robinson et al (2006, 2007) reviewed the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in those with dementia. The review, rated ++, identified one study evaluating the effectiveness of individualised behaviour management. This study, a non- randomised control trial, did not provide evidence that the intervention was effective in preventing/reducing wandering. Leeds Institute of Health Sciences July 2008 29
  30. 30. The second review (Verkaik et al, 2005; rated +) again included only one behaviour management study, although this was not the same study included in the Robinson review. The review assessed the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia; the study focussed on the use of behaviour therapy for alleviating depression. Verkaik et al concluded that there is limited evidence (one high quality randomised controlled trial) that people with probable Alzheimer’s disease living at home with depression are less depressed when their caregivers are trained in using behaviour therapy-pleasant events or behaviour therapy-problem solving rather than given standard information from a therapist or no information/training. The final review to include behaviour management interventions (Livingston et al, 2005; rated +) explored psychological approaches to the management of neuropsychiatric symptoms of dementia. Twenty five papers in the review reported on non-dementia specific psychological therapies for patients with dementia. Nearly all of the studies examined behavioural management techniques. The studies were judged to be of relatively low quality (rated 4 on a scale of 5 where a lower number indicates higher quality). The authors reported that the findings of the larger randomised controlled trials were consistent and positive, and the effects lasted for months. However, perusal of the table of evidence provided in the review does not appear to bear these conclusions out. Three randomised controlled trials report conflicting results in respect of behavioural changes; the first (n=89) reports no reduction in disruptive behaviour whilst the second (n=17) saw a significant reduction in behavioural symptoms and the third (n=8) found reduced social aggression. Similarly one randomised controlled trial (n=42) found behavioural management techniques significantly reduced depression whilst another (n=8) found no effect on depression. Leeds Institute of Health Sciences July 2008 30
  31. 31. Summary The reviews have shown that behavioural management interventions might work in alleviating some behavioural and psychological symptoms of dementia. However evidence of their effectiveness in respect of reducing wandering, depression, aggression, apathy and neuropsychiatric symptoms is inconclusive. Whilst a number of randomised controlled trials were identified they were characterised by small sample numbers. Of the two randomised controlled trials with larger sample sizes (n=89 and n=72) only one reported a positive result (reduction in depression scores). Well constructed and designed trials with larger sample sizes are required. As the reviews indicate carers may apply behaviour management techniques. The techniques are usually structured, systematically applied, time limited and, importantly, carried out under the supervision of a professional with expertise in the area17 . Cognitive Stimulation Therapy /Cognitive Training General cognitive stimulation involves a range of group activities and discussions aimed at enhancing cognitive and social functioning; similarly cognitive training involves guided practice on a set of standard tasks designed to reflect memory, attention, language or executive function (Clare and Woods 2004). Five reviews assessed evidence in this area (Clare & Woods, 2003; Grandmaison & Simard, 2003; Sitzer et al, 2006; Bates et al 2004; Livingston, 2005). Two were rated as ++ (Clare & Woods, 2003; Sitzer et al, 2006) and three as +. Focus of the reviews was improved memory and cognitive functioning, and management of neuropsychiatric symptoms. A summary of the key characteristic of the reviews are provided in table 5, p123-125. 17 http://www.sign.ac.uk/pdf/sign86.pdf Leeds Institute of Health Sciences July 2008 31
  32. 32. Clare and Woods (2003) reviewed the evidence of the effectiveness and impact of cognitive training and cognitive rehabilitation interventions aimed at improving memory and other aspects of cognitive functioning for people in the early stages of Alzheimer’s disease or vascular dementia. The review included nine studies, all randomised controlled trials. The interventions included cognitive skills remediation training, memory training or coping programmes and cognitive training. The authors reported no significant benefits of cognitive training stating that the available evidence is limited; there is no indication of any significant effects from cognitive training. However, they suggested that the use of standardised neuropsychological measures may result in positive effects on daily living capabilities going unrecognised. Similarly, the review is unable to draw any conclusion about the efficacy of individualised cognitive rehabilitation interventions for people with early stage dementia due to lack of randomised controlled trials. The Sitzer et al (2006) review was rated as ++. The review performed a meta– analysis in order to review the literature and summarise the effect of cognitive training for Alzheimer’s disease. The studies included under the cognitive training umbrella include a diverse range of interventions (including reality orientation and reminiscence therapy). The authors group the studies into either compensatory strategies (that aim to teach new ways of performing cognitive tasks by working around cognitive deficits) and restorative strategies (that aim to improve functioning in specific domains with the ultimate goal of returning function in those domains to pre-morbid levels). Using Cohen’s d, effect sizes were calculated for each cognitive domain. The authors concluded from the analysis that cognitive training evidenced promise in the treatment of Alzheimer’s disease with primarily medium effect sizes for learning memory, executive functioning, activities of daily living, general cognitive problems, depression and self-rated general functioning. Restorative strategies demonstrated the greatest effect on functioning. They note however that the results are limited due to the small number of well Leeds Institute of Health Sciences July 2008 32
  33. 33. controlled studies, small sample numbers and difficulties associated with outcome measures. Overall the review was well presented with clear analysis. However, the diversity of the interventions included mean that only broad conclusions may be drawn. It is of interest that studies identified as higher quality ‘painted a less optimistic picture of efficacy’. A review of memory stimulation programmes (Grandmaison & Simard, 2003), rated +, assessed evidence of the efficacy of stimulation strategies or programmes in Alzheimer’s disease. The 17 studies included cover visual imagery, encoding specificity strategies, errorless learning, external memory aids and dyadic training. The review concluded that it is possible to stimulate memory in Alzheimer’s disease. The errorless learning, spaced retrieval, and vanishing clues techniques, together with the dyadic approach seem to present the best training methods for patients with Alzheimer’s disease but there is a need for more randomised trials to validate the treatment approaches. The review itself was comprehensive but inclusion of only two databases for the search may have led to the exclusion of pertinent studies. As the authors indicated, whilst the evidence suggests positive results the majority of studies contain small sample numbers making identification of statistically significant improvements difficult. Bates et al (2004), in their review rated +, investigated the effectiveness of psychological interventions for people with milder dementing illness. They included one memory stimulation study. The study found no significant improvement in functional and cognitive ability and thus the review did not find any evidence of the effectiveness of procedural memory stimulation. The final review (Livingston et al, 2005), rated +, explored the management of neuropsychiatric symptoms. Livingston et al assigned the evidence from the four papers a grade representing mostly consistent evidence that cognitive stimulation therapy improves aspects of neuropsychiatric symptoms Leeds Institute of Health Sciences July 2008 33
  34. 34. immediately and for some months afterwards. All four studies were randomised controlled trials, three of the four showed positive improvements (fewer behavioural problems but returning to baseline at nine month follow up, significant decrease in depression, improvement in quality of life). Overall the review is comprehensive but it is limited by lack of detail. Two of the studies included in this review (Quayhagen et al, 1995, 2000) are also included in the Clare & Wood review. Whilst Livingston et al do not comment on the study design other than to assign a grade representing ‘mostly consistent evidence’, Clare & Wood point to methodological limitations including those relating to randomisation, performance and attrition bias in both studies. Summary In line with the aims of cognitive stimulation therapy or training, the studies within the review reflected all three main symptoms types (behavioural and psychological symptoms, cognitive function and ability to perform ADLs). The reviews point to potential benefits from cognitive rehabilitation and training – that it might work for improving memory, cognitive functioning, neuropsychiatric symptoms, behaviour, depression, quality of life, learning, and activities of daily living. The evidence presented is inconclusive. The studies included in the reviews were primarily of small sample size and whilst a number of randomised controlled trials have been carried out these appear to have methodological limitations. The meta-analysis carried out by Sitzer et al (2006) produced encouraging results reporting medium effect sizes for learning memory, executive functioning, activities of daily living, general cognitive problems, depression and self-rated general functioning. However the interventions included in the analysis, under the umbrella of cognitive training, were diverse. The review did not point to the effectiveness of any one type of cognitive training. Leeds Institute of Health Sciences July 2008 34
  35. 35. Counselling Bates et al (2004) included counselling interventions in their review of psychosocial interventions for people with milder dementing illness (see table 6, p126). The review, rated +, identified just one randomised controlled trial. They reported that counselling provided an opportunity for the client to vent their concerns and receive validated information about their mental status. However, the effectiveness of individual counselling sessions were not demonstrated on the outcome measures used (addressing recall, logical memory, and learning). The sample size of the study was small (n=20). Summary There is no evidence that counselling works for improving cognitive function (recall, logic memory or learning). However, this statement should be tempered with the caveat that only one randomised controlled trial was identified within the review and this had a small sample size. Environmental Manipulation Three reviews (Livingston, 2005; Cohen-Mansfield, 2001; Spira & Edelstein, 2006); considered studies that manipulated the environment to effect changes in neuropsychiatric symptoms and inappropriate behaviours including agitation. A summary of the key characteristic of the reviews are provided in table 7, p127-128. A review of psychological approaches to the management of neuropsychiatric symptoms of dementia (Livingston, 2005; rated +) identified 19 studies using some form of environmental manipulation. The studies within the review addressed a multitude of different behavioural challenges including wandering, aggression and agitation. Eight studies within the review investigated the effects of changing the visual environment; the authors assessed that there was consistent evidence from lower grade studies for Leeds Institute of Health Sciences July 2008 35
  36. 36. changing the environment to obscure the exit (to reduce wandering). Two studies that investigated the use of mirrors found inconclusive/inconsistent evidence (in reduction of agitation and wandering). Similarly the evidence from three studies that investigated use of signposting was judged inconclusive/inconsistent. Cohen-Mansfield (2001; rated -) reviewed the impact of non-pharmacological interventions on inappropriate behaviours. Of the six ‘environment’ studies identified two studies showed free access to an outdoor area resulted in decreased agitation; two found a simulated natural environment decreased agitated behaviours; and two report reduced agitation after initiation of a reduced stimulation environment. All the studies have small sample number and little account is taken of study design by the review. The Spira & Edelstein review (2006; rated -) of behavioural interventions to reduce agitation in older adults with dementia identified six ‘environment’ studies. In respect of wandering and hazardous behaviour the authors report that taken together the six studies show the intervention can have clinically meaningful effects on wandering in older adults with dementia; but contradictory results were obtained concerning the utility of particular stimuli. Only one study, a single subject case study assessed disruptive vocalization. The review is limited in as much as only one database was searched which is likely to have limited papers identified. Unfortunately the prevalence of single subject and case study designs together with the majority of studies measuring the occurrence of target behaviours by direct observation means this evidence is at best weak and likely to over estimate the results. Summary The interventions included in this category were diverse; they included the use of mirrors, sign-posting and access to outdoor areas. The studies were Leeds Institute of Health Sciences July 2008 36
  37. 37. characterised by small sample sizes and were typically of low quality. Indeed even between similar interventions the results were generally conflicting. The absence of robust studies (in particular randomised controlled studies) meant it was only possible to conclude that environmental manipulation might work for improving behavioural and psychological symptoms, specifically neuropsychiatric symptoms, agitation and wandering. Further evidence of effectiveness is needed. The studies included in the review were based in residential or institutional settings and as such may not be easily transferable to a home setting. However, access to an outside area such as a garden (rather than being confined indoors) may be useful in deceasing agitation or aggression. Light Therapy Light therapy involves exposure to intense levels of light under controlled conditions18 . The four papers in this section (Forbes et al, 2007; Skjerve et al, 2004; Kim et al, 2003; Cohen-Mansfield, 2001) explored the use of light therapy to manage sleep, behaviour, mood, cognition, agitation and psychological symptoms in people with dementia. A summary of the key characteristic of the reviews are provided in table 8, p129-131. The first review, Forbes et al (2007) rated ++, reviewed the efficacy of light therapy in managing disturbances of sleep, behaviour, mood and/or cognition associated with dementia. Five studies were included in the review, all were randomised controlled trials. Within the five studies bright light therapy (BLT) was typically administered by a BriteliteTM box placed about 1 metre from the participants head. The review concluded that the effects of BLT on sleep, behaviour and mood disturbances associated with dementia revealed little significant evidence of benefit; that the available studies were of poor quality and further research is required. 18 http://www.columbia.edu/~mt12/blt.htm Leeds Institute of Health Sciences July 2008 37
  38. 38. Skjerve et al (2004) explored the efficacy, clinical practicability and safety of light treatment for behavioural and psychological symptoms of dementia. The review, rated +, identified substantially more studies than the Forbes et al review (n=21) but, unlike Forbes et al, did not restrict its criteria to randomised controlled trials. Studies within the review were characterised by small sample sizes. Six of the 21 studies were randomised controlled trials and despite these trials (one with good power) showing some positive results the authors did not draw any conclusions on efficacy. Instead, they recommended study into the effects of BLT on those with mild dementia suggesting that successful treatment may be more likely for this population and may reduce the need for institutionalisation. They suggested that the different effects may be due to differences in treatment (brightness, duration, and timing) or condition (e.g. vascular dementia) which have been insufficiently tested. Whilst the Skjerve et al review is comprehensive, the process of study selection, extraction and synthesis are not presented. Kim et al (2003) evaluated the effects of bright light therapy on the sleep and behaviour of dementia patients. From the 14 studies assessed they found evidence for effectiveness inconclusive; that there is a need for controlled studies to look at the relationship between dementia, agitation, 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 Leeds Institute of Health Sciences July 2008 38
  39. 39. overall review (n=83) mean that some, but not all of the studies are described, but all are given equal weight. The review was rated -. Summary The four reviews agreed that the evidence for the use of light therapy was inconclusive; that light therapy might work when used to improve behavioural and psychological symptoms (sleep, behaviour, mood, agitation) and cognition . Whilst research has reported positive effects, the studies have been of poor quality; in particular well designed randomised controlled trials are needed. In addition, as indicated by Skjerve et al, whilst the majority of studies included in the reviews used some form of bright light lamp, the different effects may be due to differences in treatment (brightness, duration, timing) or condition (e.g. vascular dementia) which have been insufficiently tested. Massage/Touch Therapies Three reviews appraised the use of massage or touch therapies (Viggio Hansen et al, 2006; Livingston et al, 2005; Cohen-Mansfield, 2001). Of interest are behavioural and psychological symptoms (nutrition, agitation, wandering, anxiety and aggression). A summary of the key characteristic of the reviews are provided in table 9, p132-133. Viggio Hansen et al (2006) assessed the effectiveness of massage and touch therapies offered to patients with dementia (rated ++). Only two randomised controlled trials were included in their review. The interventions are gentle touch on the forearm accompanying encouragement to eat and hand massage (and calming music with hand massage). The former study reported a significant increase in mean intake of calories as well as protein in the group receiving verbal encouragement and touch (but no change in control). The latter study found a decrease in agitated behaviour greater in the group receiving hand massage than that in usual care. The review concluded that Leeds Institute of Health Sciences July 2008 39
  40. 40. some evidence is available to support the efficacy of two specific applications: the use of hand massage for an immediate and short term reduction in agitated behaviour, and the addition of touch to verbal encouragement to eat for the normalization of nutritional intake. A second review, Livingston et al (2005) rated +, reviewed psychological approaches to the management of neuropsychiatric symptoms of dementia. The authors identified three studies in this area only one of which is a randomised controlled study. The authors reported no evidence for sustained usefulness. However, the randomised controlled trial (the same study as reported by Viggio Hansen et al) that compares calming music, hand massage, music followed by massage or music and massage simultaneously for 10 minutes each, finds all groups had reduced agitation relative to usual care. The effect lasted one hour. The final review (Cohen-Mansfield, 2001), assessed as -, identified six studies that evaluated massage or touch therapies. The aims of the studies included one or more of the following: reduced wandering, agitation/anxiety and aggressiveness. Four appraised hand massage, one back massage; one is merely described as slow stroke massage. One study reported unequivocal success, the others either a positive trend, partial effects (physical and verbal behaviours) or no effect (aggression). The study designs were not clear. The large number of studies included in the overall review mean that some, but not all of the studies are described, but all are given equal weight. Summary There is evidence to suggest massage or touch therapies work in a number of areas. The evidence suggests: • Hand massage; music followed by hand massage or music and massage simultaneously each for 10 minutes can have an immediate effect and short term reduction in agitated behaviour Leeds Institute of Health Sciences July 2008 40
  41. 41. • Gentle touch on the forearm accompanying verbal encouragement can increase mean intake of calories However, there is no conclusive evidence that massage reduces wandering, anxiety or aggressiveness. Music / Music Therapy Music and music therapy has been advocated as offering possible beneficial effects on symptoms of dementia including social, emotional and cognitive skills and for decreasing behavioural problems (Koger & Brotons, 2000). Even when other abilities are seriously affected, many people still enjoy singing, dancing and listening to music19 . Approaches to music therapy differ but key to all is the development of a relationship between client and therapist20 . Music therapy typically includes one or more of the following: listening, singing or playing; the process may take place in individual or group sessions21 . Ten systematic reviews (Sung & Chang, 2005; Vink et al, 2003; Sherratt et al, 2004; Lou, 2001; Nugent, 2002; Robinson et al, 2006, 2007; Warner et al, 2006; Livingston et al, 2005; Watson & Green, 2006; Cohen-Mansfield 2001) explored the effects of music and music therapy on the treatment of those with dementia. Five of the reviews focussed only on music and music therapy for the treatment of dementia; five were more general reviews that included an assessment of the evidence on music and/or music therapy for the treatment of dementia. A summary of the key characteristic of the reviews are provided in table 10, p134-139. The reviews considered the use of music therapy for a number of symptoms including effectiveness in reducing agitated behaviour and wandering, management of neuropsychiatric symptoms, nutrition, and, more generally, 19 http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=90&pageNumber=1 20 http://www.bsmt.org/what_is_mt.htm 21 http://www.bsmt.org/what_is_mt.htm Leeds Institute of Health Sciences July 2008 41
  42. 42. emotional and behavioural responses, behavioural, social, cognitive and emotional problems and cognitive, behavioural and psychological symptoms. The majority of reviews considered a range of music and music therapies; only one (Sung & Chang, 2005) limited their review to ‘preferred music’. None confined use of music therapy only to those with Alzheimer’s disease but rather explored use of music therapy with those with dementia. The reviews were of mixed quality, four were assessed to be ++, three + and three -. With the exception of Vink et al (2003) study design was not restricted to randomised controlled trials. The Vink et al (2003) review, rated ++, assessed the efficacy of music therapy in the treatment of behavioural, social, cognitive and emotional problems of older people with dementia. Five studies were included in the review; all were randomised controlled trials. Three compared music listening with a control intervention or no intervention. The interventions included playing a patient’s preferred music compared with classical music to reduce agitation; playing preferred music during bath time to reduce occurrences of aggressive behaviour; and group music activities including listening, singing and playing compared with group reading sessions in reducing wandering behaviour. All reported music listening more effective than the control or no control. A further study compared music group therapy with conversation sessions and music therapy (intervention appears to be based primarily on singing) and the affect on language functioning. It reported music therapy to be more effective. The final study compared music therapy with puzzle activities and general activities and again was reported to be more effective in improving social and emotional functioning. However, Vink et al assessed that none of the studies presented any of the quantitative results in sufficient detail to justify the conclusions drawn. Sung and Chang (2005) provided a summary of the effects of preferred music on agitated behaviours for older people with dementia. The review included Leeds Institute of Health Sciences July 2008 42
  43. 43. eight studies (two of which were included in the Vink et al review). Whilst these two were randomised controlled trials the other studies were of a variety of designs (case study, case control, cross over with participant as own control) characterised by small sample numbers (four studies n≤5). The interventions included playing preferred music during the day and playing preferred music during bath time. The findings from the majority of included studies are positive in reducing agitated behaviours. Sung and Chang concluded that music listening interventions matched with personal preferences have positive effects in reducing occurrence of some forms of agitated behaviours in older people with dementia; but a number of methodological limitations were apparent in the studies reviewed. The review, rated ++, provides a comprehensive description of methodology, literature and findings; of particular strength is the concentration on the use of preferred music only which adds consistency. Sherratt et al (2004), rated +, reviewed 21 clinical studies looking at the effects of a variety of music on the emotional and behavioural responses in people with dementia. Whilst many of the studies included in the review mirror those included in the Vink et al and Sung and Chang reviews the study designs are not clearly described. The interventions include group music activities and listening to music. The majority of studies reported positive effects. Music was found to be effective in decreasing a range of challenging behaviours including aggression, agitation, wandering, repetitive vocalizations and irritability. Music was also found to increase reality orientation scores, time spent with one’s meal and social behaviour. Whilst the review was comprehensive and discusses a number of methodological issues (including, for example, observational data collection methods) it does not address study design in relation to assessment of quality. Lou (2001) reviewed interventions that use music to decrease agitated behaviour of the demented elderly person. All papers identified for the Leeds Institute of Health Sciences July 2008 43
  44. 44. review were included in one or more of the reviews above. The interventions were all music listening (albeit some described as background music). Lou concluded that music can be useful as an intervention to help patients deal with agitated behaviour problems and can increase patients’ quality of life but that weakness and limitations in study design are considerable. The review was rated -, because the search strategy is not clear in as much as inclusion criteria is preferably with demented elderly and no details are given of the numbers of papers identified in initial screening. Limiting the search to two databases may have reduced the papers identified. The final review whose focus was solely music and music therapy, Nugent (2002), examined the use of music and music therapy for people who have Alzheimer’s disease and related disorders (ADRDs) and display agitated behaviours. The review, rated -, supported the premise that music and music therapy interventions reduce the occurrence and frequency of agitated behaviours, that music therapy may prevent extreme forms of agitation and that the studies demonstrate that wandering and general restlessness is reduced significantly. However, the author acknowledged that more rigorous designs that include refined measuring tools and studies that have larger sample sizes are required to gather more data. The author’s conclusions were likely to overstate the effectiveness of the interventions as all studies were given equal weight irrespective of study quality and there is insufficient detail or assessment of the quality of the papers. Robinson et al (2006, 2007), rated ++, included one music therapy study in their review of the clinical and cost effectiveness and acceptability of non- pharmacological interventions to reduce wandering in dementia. The study (Groene, 1993) was included in two of the previous reviews (Vink et al and Sherratt et al). Robinson et al concluded that there is no evidence for the effectiveness of music therapy and that the identified evidence was assessed to be of low quality. This concurred with the conclusion made by Vink et al. Leeds Institute of Health Sciences July 2008 44
  45. 45. Similarly, Warner et al (2006), in their review of the effects of treatment on cognitive symptoms of dementia and the effects of treatments on behavioural and psychological symptoms of dementia, concluded that music therapy has unknown effectiveness. Their review, rated ++, identified two reviews and one subsequent randomised controlled trial. However, the conclusions are in part based on the evidence found in Vink et al review described previously (which is one of the reviews included here). The randomised controlled trial identified found that music based exercise improved cognition after three months compared with one to one conversation with a therapist but Warner et al pointed to methodological deficiencies in the trial including the possibility of allocation and assessment bias. Watson and Green (2006) reviewed evidence for interventions to assist older people with dementia to feed. The review, rated +, identified four papers that included music. The intervention in all four studies was playing music at lunchtime. The authors report that all studies showed improvements in the outcomes measured but that statistical significance was seldom reported. However the results précis provided by Watson and Green showed only two studies that report changes in feeding, food intake or food helpings; and these appear inconclusive. Within the review the quality assessment criteria is not clear and the search terms are likely to have limited identification of relevant studies. Another general review (Livingston et al, 2005; rated +) of psychological approaches to the management of neuropsychiatric symptoms of dementia identified 24 music or music therapy studies. The authors suggested that the studies show consistent evidence that music therapy decreases agitation during sessions and immediately after but that there is no evidence that music therapy is useful for treatment of neuropsychiatric symptoms in the longer term. Whilst overall it is a comprehensive review, it is let down by lack of detail in search strategy which means it is not replicable. In addition, due to Leeds Institute of Health Sciences July 2008 45
  46. 46. the very large number of papers included in the review (162), other than highlighting the randomised controlled trials, it is difficult to determine study design or details such as sample characteristics or setting. Similarly a further general review (Cohen-Mansfield, 2001, rated -) that considered the impact of non-pharmacological interventions on inappropriate behaviours in dementia reported that all but one of the 11 studies identified reports either a significant reduction or positive trend in some inappropriate behaviours. The volume of studies included in the overall review (n=83) mean that some, but not all of the studies were described, but all were given equal weight. Whilst methodological issues were presented within the discussion section, these relate to diverse measurement methods, criteria for success, screening procedures, control procedures and treatment of failures; little or no account is taken of study design. Summary The papers that explored the use of music and music therapy formed the largest grouping within this review. The evidence presented leads to the conclusion that music and music therapy does work in reducing a number of behavioural and psychological symptoms problems. These include reducing agitation, aggression, wandering and restlessness, irritability and social and emotional difficulties and improving nutritional intake. However despite the large number of studies, the reviews did identify some methodological limitations (including weak study designs and small sample numbers) which mean that the evidence is not strong. The evidence suggests the following: • Playing preferred (favourite) music may reduce agitation • Playing preferred music during bath time may reduce occurrences of aggressive behaviour Leeds Institute of Health Sciences July 2008 46
  47. 47. • Group music activities including listening, singing and playing compared may reduce wandering behaviour. Physical Activity/Exercise The beneficial effects of a physically active lifestyle in health promotion are well-documented (DH, 2004; WHO, 2004). Five systematic reviews evaluated the evidence of the effect of physical activity/exercise on mood, sleep, functional ability (activities of daily living), wandering, agitation and cognitive function for those with dementia (Eggermont & Scherder, 2006; Robinson et al, 2006, 2007; Livingston et al, 2005; Penrose, 2005; Cohen- Mansfield, 2001). The quality of the reviews varied from ++ rating to - rating. A summary of the key characteristic of the reviews are provided in table 11, p140-143. Hermans et al 2007, in their review of non-pharmacological interventions for wandering of people with dementia, also highlight the use of exercise and walking therapies that aim to prevent and/or reduce wandering but were unable to identify any studies in this area that fitted the review inclusion criteria. Eggermont & Scherder (2006), rated ++, evaluated the effect of planned physical activity programmes on mood, sleep and functional activity in people with dementia. The review included 27 studies, six of which were randomised controlled trials. The randomised controlled trials included a daily seated exercise programme, exercise to music three times a week and daily 30 minute walks. Eggermont and Scherder found, taking the methodological quality of the studies and differences between interventions into consideration, that sustained walking in particular, may benefit affective behaviour (mood) and that physical activity appears to have a beneficial impact on the quality of sleep. Based on their evaluation of the evidence they suggested that: Leeds Institute of Health Sciences July 2008 47
  48. 48. • Exercise programmes should include a walking activity and take at least 30 minutes in order to benefit mood; • Exercise should be offered frequently during the week irrespective of duration, to achieve a positive impact on sleep; • Care home residents need a long-term exercise programme with extensive sessions if a positive impact on their ADL is to be achieved (Eggermont & Scherder, 2006; p418). Robinson et al (2006, 2007) in their review, again rated as ++, attempt to determine the effectiveness and acceptability of non-pharmacological interventions to reduce wandering dementia. The review identified one randomised controlled trial that compared a moderate intensity exercise programme (aerobic/endurance activities, strength training, balance and flexibility training) with usual care. The setting was an Alzheimer’s unit in Italy. The reviewers concluded that the study provided some evidence that moderate intensive exercise may reduce wandering. Two of the remaining reviews cited inconclusive evidence. Livingston et al (2005), rated +, considered the effect of psychological approaches on neuropsychiatric symptoms. Two of the four studies identified in this review were randomised controlled trials that evaluated a walking/talking programme and a psychomotor activation programme respectively. Neither reported significant behavioural changes. Penrose (2005), rated -, appraised the role of exercise, including aerobic and resistance training, in maintaining or improving the cognitive function of persons with Alzheimer’s disease. The review concluded that there was a lack of strong evidence of statistical significance to prescribe exercise/physical activity to maintain cognitive function or prevent cognitive decline in persons with Alzheimer’s disease. However, many of the studies reported within the review did not reflect the review question and it was unclear how many Leeds Institute of Health Sciences July 2008 48
  49. 49. studies were included. The two randomised controlled trials reported both had small sample numbers (it is not clear whether more randomised controlled trials were identified). The final review that included evidence of the impact of physical activity was Cohen-Mansfield (2001) and was assessed to be rated -. The review explores the impact of non-pharmacological interventions on inappropriate behaviours. Two studies within the review focussed on outdoor walks; the intervention for the first involved escorting residents to an outdoor garden (a one to one intervention); the second consisted of group walks through common areas or outside. The review reported decreases in inappropriate behaviour for both interventions (the former found a significant decrease in physically aggressive behaviours and non-aggressive behaviours; the latter a significant decrease in agitation). It is doubtful that the findings were statistically significant given the small sample numbers (n=12 and n=11 respectively). Two more physical activity studies were included in the review table, but the author made no comment with regard to their results. Summary The evidence suggests that physical exercise does work for behavioural and psychological symptoms and functional ability; evidence from the reviews was consistent with Eggermont and Scherder (2006): • 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 Leeds Institute of Health Sciences July 2008 49
  50. 50. Reality Orientation Reality orientation aims to decrease confusion and dysfunctional behaviour patterns in people with dementia by orientating patients to time, place and person (Paton, 2006). Three reviews (Bates et al, 2004; Livingston et al, 2005; Verkaik et al, 2005), all rated +, included reality orientation studies in their paper. A summary of the key characteristic of the reviews are provided in table 12, p144. Bates et al (2004), in their review, investigated the effectiveness of psychological interventions for people with milder dementia. Two studies were identified and the authors concluded that, taking the two studies together, there is evidence that reality orientation is an effective intervention in improving cognitive ability. However, neither study demonstrated that reality orientation is effective in improving well-being or improving communication, functional performance and cognitive ability. It is of note that the studies had small sample sizes and no power calculations which could overstate positive results. Livingston et al (2005) explored psychological approaches to the management of neuropsychiatric symptoms of dementia. Their review identified 11 reality orientation studies and reported inconclusive evidence. Of the two randomised controlled included, one showed no immediate benefit compared with active ward orientation; whilst the other showed a non-significant improvement in behaviour when reminiscence therapy was preceded by reality orientation but not vice versa. The effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia was reviewed in Verkaik et al (2005). The review identified five studies, two randomised controlled trials and three case control studies. The quality of all five studies was assessed to be low. Only one study found significant improvement in depression; one further study Leeds Institute of Health Sciences July 2008 50
  51. 51. reported improvement in apathy. The authors concluded that there were no or insufficient indications that the intervention reduces depressive, aggressive or apathetic behaviours in people with dementia. Summary Reality orientation might work but the evidence presented is inconclusive. The quality of the studies included in the reviews is, as acknowledged by the review authors, low. Again the studies were characterised by small sample numbers. Whilst there are positive results reported in respect of improvements in cognitive ability, depression and apathy the reviews agree that the evidence is inconclusive. Reminiscence Therapy Reminiscence therapy involves the discussion of past activities, events and experiences with another person or group of people, usually with the aid of tangible prompts such as photographs, household and other familiar items from the past, music and archive sound recordings (Woods et al, 2005, p1). Four reviews assessed reminiscence therapy studies in respect of cognitive symptoms, mood, behavioural and psychological symptoms, management of neuropsychiatric symptoms and depressed, aggressive and apathetic behaviours in people with dementia (Warner et al, 2006; Woods et al, 2005; Livingston et al, 2005; Verkaik et al, 2005). Key characteristics of the reviews are outlined in table 13, p145-146. Warner et al (2006), in a review rated ++, explored the effects of treatment on cognitive behavioural and psychological symptoms of dementia. Within the review three studies are identified that assessed reminiscence therapy. These included one systematic review (Woods et al, 2005, discussed further below) that performed a meta-analysis and found reminiscence therapy improved cognition. The studies included in the analysis used diverse measures and Leeds Institute of Health Sciences July 2008 51
  52. 52. were often small. Warner et al recommended that larger and better studies on reminiscence therapy are needed. The Woods et al (2005) review was itself rated ++. Five randomised controlled trials were included in the review but data was extracted for only four of those studies for the meta-analysis. The inclusion criteria were such that the trials included could be either group or individual sessions involving photographs, music and videos of the past. The duration was set at a minimum of 4 weeks and 6 sessions and led by professional staff or by care- workers trained by professional staff. The interventions were either on an individual or group basis and the format of the sessions was diverse. For example, reminiscence facilitated by old photographs, books, magazines, newspapers and domestic articles or, in another study, by the development of a life story book. The authors reported results of the analysis that were statistically significant for cognition (at follow-up), mood (at follow-up), and on a measure of general behavioural function (at end of intervention period). Improvement in cognition was evident in comparison with both no treatment and social contact conditions. However, of the four randomised controlled trials included, several were very small studies, or were of relatively low quality and, as indicated above, each examined different types of reminiscence work. They concluded that more and better designed trials are needed so more robust conclusions may be drawn. Livingston et al (2005), in their review of psychological approaches to the management of neuropsychiatric symptoms of dementia, identified five reminiscence therapy studies. The review assigned a grade to the studies equivalent to troublingly inconsistent or inconclusive studies. Of the three randomised controlled trials included one found a non-significant improvement when reminiscence therapy was preceded by reality orientation Leeds Institute of Health Sciences July 2008 52
  53. 53. but not vice versa; the other found no benefit. The review itself was rated as +, whilst being comprehensive it was let down by lack of detail in the search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (n=162), other than highlighting the randomised controlled trials it was difficult to determine study design or details such as sample characteristics or setting. Another review rated as + (Verkaik et al, 2005) identified two reminiscence therapy studies within its review of the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia. One randomised controlled trial judged to be of low quality reported significantly lower self-reported depression at post-test. Whilst a case control study reports no changes in apathy. Summary In line with Woods et al, the reviews showed evidence that reminiscence therapy might work; that it has potential benefits in terms of cognition, mood and general behaviour. However these results are based on trials with small sample sizes and of relatively low quality. In addition there was variation in the type of reminiscence work reported. Thus whilst there is the potential for reminiscence therapy to be beneficial in all these areas evidence of their effectiveness is not robust. The study limitations highlighted by Woods et al need to be addressed. Snoezelen/Multi-sensory Stimulation Multi-sensory stimulation (MSS), also known as Snoezelen, is visual, auditory, tactile and olfactory stimulation offered to people in a specially designed room or environment (Baker et al, 2001). Six reviews explored the use of MSS in people with dementia. MSS was the sole focus of two reviews (Chung & Lai, 2002; Lancioni et al, 2002) whilst the remainder identified MSS studies in more general reviews (Robinson et al, 2006, 2007; Livingston et al, Leeds Institute of Health Sciences July 2008 53
  54. 54. 2005; Verkaik et al 2005; Cohen-Mansfield, 2001). The effects on disruptive behaviour, mood, depression, aggression, apathy, cognition, social/emotional behaviours, wandering and neuropsychiatric symptoms were assessed. A summary of the key characteristic of the reviews are provided in table 14, p148-149. Chung and Lai (2002), rated ++, assessed the efficacy of Snoezelen as a therapeutic intervention for older people with dementia. Including only randomised controlled trials the review identified three papers representing two trials. The first (Baker et al, 2001) compared Snoezelen to a one to one programme based on individuals’ preferences and abilities with no provision of obvious sensory inputs. The second was an extension of the first trial (Baker et al, 2003). The third paper, van Weert (2005) reported on the effect of Snoezelen on mood, behaviour and communication. The review combined the data from the latter two papers and found, in respect of behaviour, the results favoured the Snoezelen programme but there were no longer term treatment effects; no significant effects on mood were reported post intervention and no longer term effects on communication/interaction. Thus overall the review found no evidence for efficacy of Snoezelen for dementia. The review suggested there is a need for more reliable and sound 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 Leeds Institute of Health Sciences July 2008 54
  55. 55. post-session effects. However, the review was only rated – for a number of reasons. The literature search was limited; only PSYCLIT and Medical Express databases are included in the computerised search and no details were given of the search terms used, numbers of papers initially retrieved, inclusion/exclusion criteria, or process followed. In addition there was only limited discussion of study methodologies; this was divorced from the results and did not provide strong guidance on the interpretation of results from individual studies. Overall the limitations may have resulted in effects being overstated. Robinson et al (2006, 2007) in their general review that aims to determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering dementia, identified three MSS studies. All studies were randomised controlled trials. Baker et al (1998) compared Snoezelen to a one-to-one non-multi-sensory programme; Baker et al 2003 (described previously); and McNamara & Kempenaar (2001) who compared MSS with tactile stimulation. The review authors reported some evidence, albeit of poor quality, for the effectiveness of multi-sensory environment. Of the three randomised controlled trials; two did not provide evidence that a multi-sensory environment effectively prevents wandering; the third provided no follow up details and so the study yielded no information about effectiveness. The review was rated ++. Another more general review, Livingston et al (2005), rated +, assessed psychological approaches to the management of neuropsychiatric symptoms. From the six papers identified in the review, the authors concluded that there was consistent evidence from non-randomised controlled trials that the effects from MSS are apparent for only a very short time after the session. Of the three randomised controlled trials one had no clear results; two found disruptive behaviour briefly improved outside the treatment setting but there was no effect after the treatment stopped. Overall the review was Leeds Institute of Health Sciences July 2008 55
  56. 56. comprehensive but is let down by lack of detail in the search strategy which means it is not replicable. In addition, due to the very large number of papers included in the review (n=162), other than the randomised controlled trials, it was difficult to determine study design or details such as sample characteristics or setting of the studies reviewed. Verkaik et al (2005) explored the effect of psychosocial methods on depressed, aggressive and apathetic behaviours of people with dementia. Within the three studies identified they concluded that there is some evidence (from two high quality randomised controlled trials) that MSS reduces apathy in people in the latter stages of dementia. Overall the review is rated + primarily because there was no discussion of the strength of evidence for no effect / negative effect; only positive effect. The final review in this section is, again a more general review. 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. Leeds Institute of Health Sciences July 2008 56

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