'Non-pharmacological management in dementia' is really nice article published in British Journal of Psychiatry Advances. It gives basic idea about non pharmacological management in all forms of dementia for Behavioral and psychological symptoms of dementia.

1. Journal presentation
Presentor- Kapil Kulkarni, MTI Trainee
Guided by- Dr Bhan-Kotwal, Consultant Psychiatrist
Dr Davis, Consultant Psychiatrist

2. Non-pharmacological interventions
in dementia
Advances in Psychiatric Treatment May 2004, 10 (3) 171-177; DOI: 10.1192/apt.10.3.171
Simon Douglas, Ian James & Clive
Ballard

3. Introduction
• Traditionally, cognitive symptoms have been the main focus of
interest in treatment and research for people with dementia.
• Number of non-cognitive symptoms also cause problems not only
for the person with dementia and their carers, but also in clinical
management.
• The most obvious among these are agitation, aggression, mood
disorders, psychosis, sexual disinhibition, eating problems and
abnormal vocalisations.
• These symptoms are grouped together under the umbrella term
‘Behavioural and Psychological Symptoms of Dementia’ (BPSD) by
the International Psychogeriatric Association (Finkel et al, 1996).

4. • These symptoms are a common reasons for admission in hospital
and they increase stress of caregivers (Schultz & Williamson, 1991).
• As good clinical practice, clinician should first exclude the possibility
that BPSD are the consequence of concurrent physical illness (e.g.
infections, constipation), and second to try non-pharmacological
approaches before considering pharmacological interventions.
• However, in practice, pharmacological approaches are used as the
first-line treatment, despite the modest evidence of efficacy from
clinical trials (Ballard & O’Brien, 1999).
Introduction

5. • More than 40% of people with dementia in care facilities in the
developed world are taking neuroleptic drugs which are
inappropriate and unnecessary (Margallo-Lana et al, 2001).
• These prescription often cause side-effects such as sedation, falls
and extrapyramidal signs.
• Neuroleptics in dementia can accelerate cognitive decline, reduce
well-being and quality of life. (Ballard et al, 2001) (McShane et al,
1997).
Introduction

6. • This article discusses the types of BPSD that are appropriate for
intervention and then examines the current use of non-
pharmacological interventions.
• The therapies in this article are intended to apply to all common
late-onset dementias and to no particular subtype.
• Extensive review of the literature on non-pharmacological
treatments was carried out using Medline and other searches, but
this is not a formal systematic review.
Introduction

7. The nature of the behaviours
• Definitions of term ‘non-cognitive’ symptom are debatable.
• Currently favoured term for non cognitive symptoms is BPSD, but
still most of the psychology community use the label ‘challenging
behaviour’ (Emerson et al, 1995).
• Non cognitive symptoms are further classified by Allen-Burge as
follows: (e.g. Cohen-Mansfield et al, 1992; Allen-Burge et al, 1999).
1. Behavioural excesses (like disruptive vocalisation or aggression)
2. Behavioural deficits (e.g. lack of social interaction or lack of self-
care).
• The main focus of treatment usually is behavioural excess, as they
cause more disruption to person with dementia and their carers.

8. • Disruptive behaviours are often taken as an indication of underlying
distress or unmet need.
• ‘Unmet needs model for agitation’ distinguishes three main
functions of behaviours in relation to needs: (Cohen-Mansfield
2000)
1. Behaviours to obtain a need (e.g. pacing to provide stimulation);
2. Behaviours to communicate a need (e.g. repetitive questioning);
3. Behaviours resulting from an unmet need (e.g. aggression
triggered by pain or discomfort).
• This model focuses on the patient’s needs so we can target
interventions more appropriately (e.g. the use of pain relief,
facilitation of communication).
The nature of the behaviours

9. Non-pharmacological interventions
• An increasing number of non-pharmacological therapies are now
available for people with dementia.
• It should be noted that there are several areas of overlap between
these therapies and, in fact, each approach is rarely used in
isolation (Ballard et al, 2001).

10. Non-pharmacological therapies
Standard therapies
Behavioural therapy
Reality orientation
Validation therapy
Reminiscence therapy
Alternative therapies
Art therapy
Music therapy
Activity therapy
Complementary therapy
Aromatherapy
Bright-light therapy
Multisensory approaches
Brief psychotherapies
Cognitive–behavioural therapy
Interpersonal therapy

11. Standard therapies
Behavioural therapy
• Based on principles of conditioning and learning theory, it aims to
suppress or eliminate challenging behaviours.
• Positive programming methods have been used with non-aversive
techniques to develop more functional behaviours (La Vigna &
Donnellan, 1986).
• Behavioural analysis is often a starting point of therapy and modern
behavioural approaches are wholly consistent with person-centred
care (Moniz-Cook 1998).
• Initial assessment includes identification of triggers, behaviours and
reinforcers and making their relationships clear to patient.

12. • Assessment is done by using chart or diary to gather information
about symptoms and the sequence of actions leading up to it.
• Interventions are then based on an analysis of these findings.
• Three key features are focused while designing an intervention
(Emerson 1998) :
1. Taking account of the individual’s preferences
2. Changing the context in which the behaviour takes place
3. Using reinforcement strategies and schedules
to reduce the behaviour
Standard therapies
Behavioural therapy

13. Standard therapies
Behavioural therapy
• The efficacy of behavioural therapy in dementia is demonstrated by
showing successful reductions in wandering, incontinence and
other forms of stereotypical behaviours (Burgio & Fisher, 2000)
(Woods, 1999).
• Some case studies have noted that the behaviours had diverse
causes and maintaining factors so behavioural interventions must
be tailored to individual cases (Meares & Draper 1999).

14. Standard therapies
Reality orientation
• One of the most widely used management strategies for people
with dementia (Holden & Woods, 1995).
• Used either with individuals or groups and it helps people by
reminding them facts about themselves and their environment.
• A range of materials and activities are used in reality orientation, for
example signposts, notices and other memory aids.
• Although its efficacy is debatable, reality orientation sessions could
increase people’s verbal orientation in comparison with untreated
control groups (Bleathman & Morton 1988).
• It reminds the participants of their deterioration (Goudie & Stokes,
1989).

15. Standard therapies
Reality orientation
• However this can cause lowering of mood initially in those
attending the sessions (Baines et al 1987).
• Carers may experience frustration as they are repeatedly trying to
orient individuals, with little noticeable long-term effect (Hitch,
1994).
• Efficacy of reality orientation has been favoured by six RCTs and, the
authors proposed a further step for rehabilitation of reality
orientation (Spector et al’s 2002a).

16. Standard therapies
Validation therapy
• This was developed as an antidote to the perceived lack of efficacy
of reality orientation.
• Its originator, Naomi Feil, suggested that some features of dementia
such as repetition and retreating into the past were active
strategies by affected individual to avoid stress, boredom and
loneliness.
• She argues that people with dementia can retreat into an inner
reality based on feelings rather than intellect, as they find the
present reality too painful.
• Emotional content is considered more important than the person’s
orientation to the present.
• Validation therapists therefore empathise the feelings and
meanings hidden behind their confused speech and behaviour.

17. Standard therapies
Validation therapy
• One study assessing efficacy of validation therapy noted that it
promotes contentment, results in less negative affect and
behavioural disturbance, produces positive effects and provides the
individual with insight into external reality (Hitch 1994).
• Another study, after evaluation of cognitive and behavioural
measures concluded that despite some positive indicators, the jury
was still out with respect to its efficacy (Neal & Briggs 2002).

18. Standard therapies
Reminiscence therapy
• It helps a person with dementia to relive past experiences,
especially those that might be positive and personally significant,
for example family holidays and weddings.
• It increases levels of well-being by providing pleasure and cognitive
stimulation.
• It is stated that premorbid aspects of the personality may re-
emerge during reminiscence work (Woods, 1999).
• The therapy has a great deal of flexibility as it can be adapted to the
individual. For example, a person with severe dementia can still
gain pleasure from listening to an old song.

19. • Two RCT showed that there was little evidence of a significant
impact of reminiscence therapy and little indication of cognitive
improvement (Spector et al 2002b).
• Other evidence suggests improvements in behaviour, well-being,
social interaction, self-care and motivation (O’Donovan 1993)
(Gibson, 1994).
Standard therapies
Reminiscence therapy

20. Alternative therapies
• As in other areas of health care, alternative therapies are gaining
currency in the treatment of people with dementia.
• These therapies still lack empirical evidence relating to their
effectiveness, but this issue is gradually being addressed (Marshall
& Hutchinson, 2001).

21. Alternative therapies
Art therapy
• Art therapy has been recommended in dementia as it has potential
to provide meaningful stimulation, improve social interaction and
improve levels of self-esteem (Killick & Allan 1999).
• Activities such as drawing and painting are thought to provide the
opportunity for self-expression and the chance to exercise some
choice in terms of the colours and themes of their creations.

22. • This involves engagement in a musical activity (e.g. singing or
playing an instrument), or merely listening to songs or music which
is shown to benefit people with dementia (Killick & Allan, 1999).
• Music therapy significantly reduces abnormal vocalisation and
agitation (Cohen-Mansfield & Werner 1997) (Gerdner 2000).
• It increases levels of well-being, allows better social interaction and
improves autobiographical memory in dementia groups who
regularly had music played to them (Lord & Garner 1993).
Alternative therapies
Music therapy

23. • It involves amorphous group of recreations such as exercise, dance,
sport and drama.
• Physical exercise gives benefits to people with dementia by
reducing the number of falls, improving their sleep, mood and
confidence (King et al, 1997) (Young & Dinan, 1994).
• Daytime exercise helps to reduce daytime agitation and night-time
restlessness. (Alessi et al, 1999)..
Alternative therapies
Activity therapy

24. • In dance therapy, a form of dance known as ‘jabadeo’ is described,
which involves no steps or motions but allows the participants to
engage with each other in interactive movements (Perrin, 1998).
• This might fulfil a need for non-sexual physical contact which many
people with dementia find soothing.
Alternative therapies
Activity therapy

25. Alternative therapies
Complementary therapy
• A number of different complementary therapies are available:
massage, reflexology, reiki, therapeutic healing, herbal medicine
and aromatherapy.
• Most of them have not received a great deal of empirical
investigation. An exception to this is aromatherapy.

26. Alternative therapies
Complementary therapy: Aromatherapy
• It is one of the fastest growing of all the complementary therapies
(Burns et al, 2002).
• It uses oil extracted from lavender and melissa balm.
• Advantage- Several routes of administration such as inhalation,
bathing, massage and topical application in a cream.
• So the therapy can be targeted at individuals with different
behaviours. For example, inhalation may be more effective than
massage for a person with restlessness.

27. • Other advantages- It has positive image, its use helps interaction
while providing a sensory experience and it is well tolerated in
comparison with medication.
• Controlled trials have noted positive effects which include
significant reductions in agitation, with excellent compliance and
tolerability (Ballard et al, 2002).
Alternative therapies
Complementary therapy: Aromatherapy

28. Alternative therapies
Bright light therapy
• It improves fluctuations in diurnal rhythms that may account for
night-time disturbances and ‘sundown syndrome’ in people with
dementia (recurring confusion or agitation in the late afternoon or
early evening).
• Three recent controlled trials showed evidence for improving
restlessness and with particular benefit for sleep disturbances
(Haffmanns et al, 2001).

29. • It usually involve using a room designed to provide several types of
sensory stimulation such as light (often in the form of fibre optics
which can move and be flexible), texture (cushions and vibrating
pads), smell and sound.
• The use of these resources is tailored to the needs of individual so
all forms of stimulation are not used in one session.
• Use of multisensory rooms has centred mainly on those with more
severe symptoms.
• A study showed some positive effects
on agitation, but the results failed to
reach significance. (van Diepen et al, 2002)
Alternative therapies
Multisensory stimulation

30. Brief psychotherapies
Cognitive–behavioural therapy:
• It states that behavioural difficulties in dementia emerge through
one or more of the following cognitive features: cognitive
misinterpretations, biases, distortions, and communication
difficulties. (James et al, 1999; James, 2001).
• Some studies reported positive findings with CBT in the early stages
of Alzheimer’s disease (Teri & Gallagher-Thompson 1991).
• Both individual and group CBT have shown some favourable results
(Kipling et al, 1999).

31. Interpersonal therapy:
• It examines the individual’s distress in interpersonal context
through one of four domains: interpersonal disputes; interpersonal
difficulties; bereavement; and role transitions (Weissman et al,
2000).
• Despite evidence of the success, it has only recently been used with
dementia (James et al, 2003) (Miller & Reynolds, 2002).
Limitations:
• Both CBT and IPT have limitations,
particularly with severe dementia.
Brief psychotherapies

32. Conclusions
• The field of dementia care is expanding, with an increasing number
of articles on psychosocial interventions.
• After reviewing many of the available treatments, it is worth noting
their common features. These therapies:
1. Move towards more person-centred care (Kitwood, 1997).
2. Make attempts to understand the individual’s experience of
dementia and to improve quality of life.
3. Have systemic perspective, that is, the need to work with systems
(families, professional carers, organisations, etc).
• Care staff and families are usually integral to treatment strategies,
hence training of carers (both professional and family) is an
important part of treatment programmes.

33. • The fundamental weakness within the available literature is that it
requires clearly addressing process issues (i.e. details outlining the
mechanism of change occurring with interventions).
• The available studies present the contents of intervention very well,
but usually fail to outline processes ( like communication strategies,
interpersonal style, feedback mechanisms, staff training issues).
• Highlighting these issues in better ways would help therapists to
develop, refine and improve treatment programmes (James et al,
2003).
Conclusions