Advances in Psychiatric Treatment(2004),vol.10,171-179 Non-pharmacological interventions in dementia Simon Douglas,Ian James Clive Ballard Abstract It is increasingly recognised that pharmacological treatments for dementia should be used as a second- line approach and that non-pharmacological options should,in best practice,be pursued first.This review examines current non-pharmacological approaches.It highlights the more traditional treatments such as behavioural therapy.reality orientation and validation therapy,and also examines the potential of interesting new alternative options such as cognitive therapy,aromatherapy and multisensory therapies.The current literature is explored with particular reference to recent research. especially randomised controlled trials in the area.Although many non-pharmacological treatments have reported benefits in multiple research studies,there is a need for further reliable and valid data before the efficacy of these approaches is more widely recognised. Traditionally,cognitive problems have been the treatment,despite the modest evidence of efficacy main focus of interest in treatment and research for from clinical trials where high placebo response people with dementia.It is becoming increasingly rates are frequently seen(Ballard O'Brien,1999). recognised,however,that a number of common non- Inappropriate and unnecessary prescribing has cognitive symptoms also provide problems not only become such a problem that more than 40%of people for the person with dementia and the carers,but with dementia in care facilities in the developed also in relation to clinical management.The most world are taking neuroleptic drugs(Margallo-Lana obvious are agitation,aggression,mood disorders et al,2001).The prescription of these medications and psychosis,but other important symptoms without attempting other treatment options is of par- include sexual disinhibition,eating problems and ticular concern because of the substantial adverse abnormal vocalisations.These have been grouped effects associated with their use,especially in people together under the umbrella term'behavioural and with dementia.Side-effects such as sedation,falls psychological symptoms of dementia'(BPSD)by the and extrapyramidal signs are well-known.and more International Psychogeriatric Association (Finkel recent work indicates that neuroleptic treatment of et al,1996).These symptoms are a common reason dementia leads to reduced well-being and quality for institutionalisation of people with dementia and of life (Ballard et al,2001)and may even accelerate they increase the burden and stress of caregivers cognitive decline (McShane et al,1997). (Schultz Williamson,1991).Good clinical practice In this article we discuss the types of behavioural requires the clinician first to exclude the possibility and psychological symptoms that are appropriate that behavioural or psychological symptoms are the for intervention,and then examine the current use consequence of concurrent physical illness (e.g. of non-pharmacological interventions.The article infections,constipation),and second to try non- is intended to apply to all common late-onset pharmacological approaches before considering dementias and to no subtype in particular. pharmacological interventions. We carried out an extensive review of the literature All too often in practice,however,pharmaco- on non-pharmacological treatments for dementia logical approaches involving neuroleptic or other using Medline and other related searches,but this sedative medication are used as the first-line is not intended to be a formal systematic review. Simon Douglas is a clinical research nurse at the Wolfson Research Centre in Newcastle upon Tyne.He is currently coordinating a number of studies,particularly on dementia in nursing and residential homes and providing input into a new trial of non- pharmacological interventions for dementia.Ian James is a consultant clinical psychologist at the Centre for the Health of the Elderly at Newcastle General Hospital and a research tutor at the Univeristy of Newcastle upon Tyne.His current interests are in using interventions such as cognitive-behavioural and interpersonal therapy with elderly patients and their care staff to deal with challenging behaviour.Clive Ballard (Wolfson Research Centre,Newcastle General Hospital,Westgate Road.Newcastle NE4 6BE,UK.E-mail:c.g.ballard@nclac.uk)has recently taken up post as Professor of Age Related Disorders at Kings College London/Institute of Psychiatry,having previously been Professor of Old Age Psychiatry at the Univeristy of Newcastle upon Tyne.Ongoing research programmes include forms of dementia.psychatric symptoms of dementia and the use of sedative drugs in dementia. 171
Non-pharmacological interventions in dementia Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 171 Advances in Psychiatric Treatment (2004), vol. 10, 171–179 Traditionally, cognitive problems have been the main focus of interest in treatment and research for people with dementia. It is becoming increasingly recognised, however, that a number of common noncognitive symptoms also provide problems not only for the person with dementia and the carers, but also in relation to clinical management. The most obvious are agitation, aggression, mood disorders and psychosis, but other important symptoms include sexual disinhibition, eating problems and abnormal vocalisations. These have been grouped together under the umbrella term ‘behavioural and psychological symptoms of dementia’ (BPSD) by the International Psychogeriatric Association (Finkel et al, 1996). These symptoms are a common reason for institutionalisation of people with dementia and they increase the burden and stress of caregivers (Schultz & Williamson, 1991). Good clinical practice requires the clinician first to exclude the possibility that behavioural or psychological symptoms are the consequence of concurrent physical illness (e.g. infections, constipation), and second to try nonpharmacological approaches before considering pharmacological interventions. All too often in practice, however, pharmacological approaches involving neuroleptic or other sedative medication are used as the first-line treatment, despite the modest evidence of efficacy from clinical trials where high placebo response rates are frequently seen (Ballard & O’Brien, 1999). Inappropriate and unnecessary prescribing has become such a problem that more than 40% of people with dementia in care facilities in the developed world are taking neuroleptic drugs (Margallo-Lana et al, 2001). The prescription of these medications without attempting other treatment options is of particular concern because of the substantial adverse effects associated with their use, especially in people with dementia. Side-effects such as sedation, falls and extrapyramidal signs are well-known, and more recent work indicates that neuroleptic treatment of dementia leads to reduced well-being and quality of life (Ballard et al, 2001) and may even accelerate cognitive decline (McShane et al, 1997). In this article we discuss the types of behavioural and psychological symptoms that are appropriate for intervention, and then examine the current use of non-pharmacological interventions. The article is intended to apply to all common late-onset dementias and to no subtype in particular. We carried out an extensive review of the literature on non-pharmacological treatments for dementia using Medline and other related searches, but this is not intended to be a formal systematic review. Non-pharmacological interventions in dementia Simon Douglas, Ian James & Clive Ballard Abstract It is increasingly recognised that pharmacological treatments for dementia should be used as a secondline approach and that non-pharmacological options should, in best practice, be pursued first. This review examines current non-pharmacological approaches. It highlights the more traditional treatments such as behavioural therapy, reality orientation and validation therapy, and also examines the potential of interesting new alternative options such as cognitive therapy, aromatherapy and multisensory therapies. The current literature is explored with particular reference to recent research, especially randomised controlled trials in the area. Although many non-pharmacological treatments have reported benefits in multiple research studies, there is a need for further reliable and valid data before the efficacy of these approaches is more widely recognised. Simon Douglas is a clinical research nurse at the Wolfson Research Centre in Newcastle upon Tyne. He is currently coordinating a number of studies, particularly on dementia in nursing and residential homes and providing input into a new trial of nonpharmacological interventions for dementia. Ian James is a consultant clinical psychologist at the Centre for the Health of the Elderly at Newcastle General Hospital and a research tutor at the Univeristy of Newcastle upon Tyne. His current interests are in using interventions such as cognitive–behavioural and interpersonal therapy with elderly patients and their care staff to deal with challenging behaviour. Clive Ballard (Wolfson Research Centre, Newcastle General Hospital, Westgate Road, Newcastle NE4 6BE, UK. E-mail: c.g.ballard@ncl.ac.uk) has recently taken up post as Professor of Age Related Disorders at Kings’ College London/Institute of Psychiatry, having previously been Professor of Old Age Psychiatry at the Univeristy of Newcastle upon Tyne. Ongoing research programmes include forms of dementia, psychatric symptoms of dementia and the use of sedative drugs in dementia
Douglas et al/Woods The nature of the behaviours challenging behaviours.More recently.positive pro- gramming methodologies(La Vigna Donnellan, When reviewing this area,it is important to note 1986)have used non-aversive methods in helping that there is an ongoing debate regarding the to develop more functional behaviours.Moniz-Cook definitions and basic terminology for 'non-cognitive (1998)suggests that behavioural analysis is often symptoms.The term currently favoured in the the starting point of most other forms of therapeutic psychiatric literature is 'behavioural and psycho- intervention in this area.Furthermore,she suggests logical symptoms of dementia,but most of the psy- that modern behavioural approaches can be wholly chology community still use the label 'challenging consistent with person-centred care.Behavioural behaviour'Emerson et al.1995).Within these therapy requires a period of detailed assessment in broader terms,further distinctions have been made which the triggers,behaviours and reinforcers(also (e.g.Cohen-Mansfield et al,1992;Allen-Burge et al, known as the ABC:antecedents,behaviours and 1999).Allen-Burge et al distinguish between consequences)are identified and their relationships behavioural excesses (such as disruptive vocal- made clear to the patient.The therapist will often isation or aggression)and behavioural deficits(such use some kind of chart or diary to gather information as lack of social interaction or lack of self-care). about the manifestations of a behaviour and the In Allen-Burge et al's terminology,until recently sequence of actions leading up to it.Interventions the main focus of treatment has been excessive are then based on an analysis of these findings. behaviours,because of the disruption they cause Emerson(1998)suggests focusing on three key both for the person with dementia and the carers. features when designing an intervention:taking It is relevant to note that,in many currently used account of the individual's preferences;changing approaches,the disruptive behaviours are often not the context in which the behaviour takes place;and addressed directly,but are taken as an indication of using reinforcement strategies and schedules that underlying distress or unmet need.For example, reduce the behaviour. Cohen-Mansfield(2000)has recently produced an The efficacy of behavioural therapy has been 'unmet needs model for agitation'.Her model demonstrated in the context of dementia in only a distinguishes three main functions of behaviours small number of studies(Burgio Fisher,2000).For in relation to needs:behaviours to obtain or meet a example,there is evidence of successful reductions need(e.g.pacing to provide stimulation);behaviours in wandering,incontinence and other forms of to communicate a need (e.g.repetitive questioning); stereotypical behaviours (Woods,1999).Meares and behaviours that result from an unmet need(e.g. Draper(1999)presented case studies testifying to aggression triggered by pain or discomfort).This the efficacy of behavioural therapy,but they noted model is particularly helpful in terms of therapy that the behaviours had diverse causes and because the focus on the patient's needs helps to maintaining factors,and advised that behavioural target interventions more appropriately (e.g.the use interventions must be tailored to individual cases. of pain relief,facilitation of communication). Non-pharmacological Box 1 Non-pharmacological therapies interventions Standard therapies An increasing number of non-pharmacological Behavioural therapy Reality orientation therapies are now available for people with dementia Validation therapy (Box 1).It should be noted that there are several areas Reminiscence therapy of overlap between these therapies and,in fact,each approach is rarely used in isolation (Ballard et al, Alternative therapies 2001).It is therefore important for a clinician to have Art therapy some knowledge of a number of these approaches, Music therapy enabling a combination of treatments tailored to the Activity therapy individual requirements of the patient. Complementary therapy Aromatherapy Standard non-pharmacological therapies Bright-light therapy Multisensory approaches Behavioural therapy Briefpsychotherapies Traditionally,behavioural therapy has been based Cognitive-behavioural therapy on principles of conditioning and learning theory Interpersonal therapy using strategies aimed at suppressing or eliminating 172 Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/
172 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ Douglas et al/Woods The nature of the behaviours When reviewing this area, it is important to note that there is an ongoing debate regarding the definitions and basic terminology for ‘non-cognitive’ symptoms. The term currently favoured in the psychiatric literature is ‘behavioural and psychological symptoms of dementia’, but most of the psychology community still use the label ‘challenging behaviour’ (Emerson et al, 1995). Within these broader terms, further distinctions have been made (e.g. Cohen-Mansfield et al, 1992; Allen-Burge et al, 1999). Allen-Burge et al distinguish between behavioural excesses (such as disruptive vocalisation or aggression) and behavioural deficits (such as lack of social interaction or lack of self-care). In Allen-Burge et al’s terminology, until recently the main focus of treatment has been excessive behaviours, because of the disruption they cause both for the person with dementia and the carers. It is relevant to note that, in many currently used approaches, the disruptive behaviours are often not addressed directly, but are taken as an indication of underlying distress or unmet need. For example, Cohen-Mansfield (2000) has recently produced an ‘unmet needs model for agitation’. Her model distinguishes three main functions of behaviours in relation to needs: behaviours to obtain or meet a need (e.g. pacing to provide stimulation); behaviours to communicate a need (e.g. repetitive questioning); and behaviours that result from an unmet need (e.g. aggression triggered by pain or discomfort). This model is particularly helpful in terms of therapy because the focus on the patient’s needs helps to target interventions more appropriately (e.g. the use of pain relief, facilitation of communication). Non-pharmacological interventions An increasing number of non-pharmacological therapies are now available for people with dementia (Box 1). 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). It is therefore important for a clinician to have some knowledge of a number of these approaches, enabling a combination of treatments tailored to the individual requirements of the patient. Standard non-pharmacological therapies Behavioural therapy Traditionally, behavioural therapy has been based on principles of conditioning and learning theory using strategies aimed at suppressing or eliminating challenging behaviours. More recently, positive programming methodologies (La Vigna & Donnellan, 1986) have used non-aversive methods in helping to develop more functional behaviours. Moniz-Cook (1998) suggests that behavioural analysis is often the starting point of most other forms of therapeutic intervention in this area. Furthermore, she suggests that modern behavioural approaches can be wholly consistent with person-centred care. Behavioural therapy requires a period of detailed assessment in which the triggers, behaviours and reinforcers (also known as the ABC: antecedents, behaviours and consequences) are identified and their relationships made clear to the patient. The therapist will often use some kind of chart or diary to gather information about the manifestations of a behaviour and the sequence of actions leading up to it. Interventions are then based on an analysis of these findings. Emerson (1998) suggests focusing on three key features when designing an intervention: taking account of the individual’s preferences; changing the context in which the behaviour takes place; and using reinforcement strategies and schedules that reduce the behaviour. The efficacy of behavioural therapy has been demonstrated in the context of dementia in only a small number of studies (Burgio & Fisher, 2000). For example, there is evidence of successful reductions in wandering, incontinence and other forms of stereotypical behaviours (Woods, 1999). Meares & Draper (1999) presented case studies testifying to the efficacy of behavioural therapy, but they noted that the behaviours had diverse causes and maintaining factors, and advised that behavioural interventions must be tailored to individual cases. Box 1 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
Non-pharmacological interventions in dementia Reality orientation and behavioural disturbance,produces positive effects and provides the individual with insight into Reality orientation is one of the most widely used external reality.It was,however,suggested that management strategies for dealing with people with therapists could become too focused on confused dementia(for a review,see Holden Woods,1995). communication and could fail to identify simple It aims to help people with memory loss and explanations such as pain or hunger.Neal Briggs disorientation by reminding them of facts about (2002)evaluated validation therapy across a number themselves and their environment.It can be used of controlled trials,employing cognitive and both with individuals and with groups.In either behavioural measures.They concluded that despite case,people with memory loss are oriented to their some positive indicators,the jury was still out with environment using a range of materials and respect to its efficacy. activities.This involves consistent use of orientation devices such as signposts,notices and other memory Reminiscence therapy aids.There is debate regarding the efficacy of the approach,although Bleathman Morton(1988) Reminiscence therapy involves helping a person found that reality orientation sessions could increase with dementia to relive past experiences,especially people's verbal orientation in comparison with those that might be positive and personally untreated control groups.However,it has also been significant,for example family holidays and claimed that reality orientation can remind the weddings.This therapy can be used with groups or participants of their deterioration(Goudie Stokes, with individuals.Group sessions tend to use 1989),and Baines et al(1987)found an initial activities such as art,music and artefacts to provide lowering of mood in those attending the sessions.It stimulation.Reminiscence therapy is seen as a way has also been suggested that carers may experience of increasing levels of well-being and providing further frustration at using the method and at having pleasure and cognitive stimulation.Few high- repeatedly to try to orient individuals,with little quality studies have been conducted in this area, noticeable long-term effect (Hitch,1994).Despite and Spector et al(2002b)identified only two these concerns,the debate concerning efficacy has randomised controlled trials.From their limited been largely settled following Spector et al's(2002a) data-set they concluded that there was little evidence favourable review of the six randomised controlled of a significant impact of the approach.O'Donovan trials of this therapy.Indeed,on the basis of the (1993).however,stated that,although there is little positive findings,the authors proposed that it was indication of cognitive improvement,there is some time for a rehabilitation of reality orientation.They evidence suggesting improvements in behaviour, had previously developed a pilot programme to this well-being,social interaction,self-care and motiv- effect(Spector et al,2001). ation(Gibson,1994).It is also claimed that premorbid aspects of the person's personality may re-emerge Validation therapy during reminiscence work (Woods,1999).The therapy also has a great deal of flexibility as it can Validation therapy was developed as an antidote to be adapted to the individual.A person with severe the perceived lack of efficacy of reality orientation. dementia can still gain pleasure from listening to It was suggested by its originator,Naomi Feil,that an old record.for instance some of the features associated with dementia such as repetition and retreating into the past were in fact active strategies on the part of the affected Alternative non-pharmacological individual to avoid stress.boredom and loneliness. therapies She argues that people with dementia can retreat As in other areas of health care,alternative therapies into an inner reality based on feelings rather than intellect,as they find the present reality too painful. are gaining currency in the treatment of people with Validation therapy therapists therefore attempt to dementia.These therapies often still lack empirical communicate with individuals with dementia by evidence relating to their effectiveness (Marshall empathising with the feelings and meanings hidden Hutchinson,2001).but this issue is gradually being behind their confused speech and behaviour.It is addressed.A review of some of the most popular the emotional content of what is being said that is forms of alternative therapy is provided below. more important than the person's orientation to the present.There have been relatively few empirical Art therapy studies assessing the efficacy of the validation Art therapy has been recommended as a treatment approach,as noted by Feil(1967).Mitchell(1987)and for people with dementia as it has the potential to Hitch(1994).Hitch noted that validation therapy provide meaningful stimulation,improve social promotes contentment,results in less negative affect interaction and improve levels of self-esteem(Killick Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/ 173
Non-pharmacological interventions in dementia Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 173 Reality orientation Reality orientation is one of the most widely used management strategies for dealing with people with dementia (for a review, see Holden & Woods, 1995). It aims to help people with memory loss and disorientation by reminding them of facts about themselves and their environment. It can be used both with individuals and with groups. In either case, people with memory loss are oriented to their environment using a range of materials and activities. This involves consistent use of orientation devices such as signposts, notices and other memory aids. There is debate regarding the efficacy of the approach, although Bleathman & Morton (1988) found that reality orientation sessions could increase people’s verbal orientation in comparison with untreated control groups. However, it has also been claimed that reality orientation can remind the participants of their deterioration (Goudie & Stokes, 1989), and Baines et al (1987) found an initial lowering of mood in those attending the sessions. It has also been suggested that carers may experience further frustration at using the method and at having repeatedly to try to orient individuals, with little noticeable long-term effect (Hitch, 1994). Despite these concerns, the debate concerning efficacy has been largely settled following Spector et al’s (2002a) favourable review of the six randomised controlled trials of this therapy. Indeed, on the basis of the positive findings, the authors proposed that it was time for a rehabilitation of reality orientation. They had previously developed a pilot programme to this effect (Spector et al, 2001). Validation therapy Validation therapy was developed as an antidote to the perceived lack of efficacy of reality orientation. It was suggested by its originator, Naomi Feil, that some of the features associated with dementia such as repetition and retreating into the past were in fact active strategies on the part of the 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. Validation therapy therapists therefore attempt to communicate with individuals with dementia by empathising with the feelings and meanings hidden behind their confused speech and behaviour. It is the emotional content of what is being said that is more important than the person’s orientation to the present. There have been relatively few empirical studies assessing the efficacy of the validation approach, as noted by Feil (1967), Mitchell (1987) and Hitch (1994). Hitch noted that validation therapy promotes contentment, results in less negative affect and behavioural disturbance, produces positive effects and provides the individual with insight into external reality. It was, however, suggested that therapists could become too focused on confused communication and could fail to identify simple explanations such as pain or hunger. Neal & Briggs (2002) evaluated validation therapy across a number of controlled trials, employing cognitive and behavioural measures. They concluded that despite some positive indicators, the jury was still out with respect to its efficacy. Reminiscence therapy Reminiscence therapy involves helping a person with dementia to relive past experiences, especially those that might be positive and personally significant, for example family holidays and weddings. This therapy can be used with groups or with individuals. Group sessions tend to use activities such as art, music and artefacts to provide stimulation. Reminiscence therapy is seen as a way of increasing levels of well-being and providing pleasure and cognitive stimulation. Few highquality studies have been conducted in this area, and Spector et al (2002b) identified only two randomised controlled trials. From their limited data-set they concluded that there was little evidence of a significant impact of the approach. O’Donovan (1993), however, stated that, although there is little indication of cognitive improvement, there is some evidence suggesting improvements in behaviour, well-being, social interaction, self-care and motivation (Gibson, 1994). It is also claimed that premorbid aspects of the person’s personality may re-emerge during reminiscence work (Woods, 1999). The therapy also has a great deal of flexibility as it can be adapted to the individual. A person with severe dementia can still gain pleasure from listening to an old record, for instance. Alternative non-pharmacological therapies As in other areas of health care, alternative therapies are gaining currency in the treatment of people with dementia. These therapies often still lack empirical evidence relating to their effectiveness (Marshall & Hutchinson, 2001), but this issue is gradually being addressed. A review of some of the most popular forms of alternative therapy is provided below. Art therapy Art therapy has been recommended as a treatment for people with dementia as it has the potential to provide meaningful stimulation, improve social interaction and improve levels of self-esteem (Killick
Douglas et al/Woods Allan 1999).Activities such as drawing and healing,herbal medicine and aromatherapy.The painting are thought to provide individuals with results of this survey have been reviewed by Wiles the opportunity for self-expression and the chance Brooker (2003).In terms of effectiveness,it was to exercise some choice in terms of the colours and evident that careful consideration was needed to themes of their creations. identify what was meant by 'effective'(e.g.were the therapies aiming to improve cognitive abilities or Music therapy levels of well-being?). Several studies have reported benefits gained by In general,most of the complementary therapies have not received a great deal of empirical investi- people with dementia from music therapy(Killick gation.An exception to this is aromatherapy,which Allan,1999).The therapy may involve engagement is described in more detail below. in a musical activity (e.g.singing or playing an instrument),or merely listening to songs or music. Aromatherapy Lord Garner (1993)showed increases in levels of well-being,better social interaction and improve- Aromatherapy is one of the fastest growing of all ments in autobiographical memory in a group of the complementary therapies (Burns et al,2002). nursing home residents who regularly had music It appears to have several advantages over the played to them.Such improvements were not pharmacological treatments widely used for observed in a comparison group engaged in other dementia.It has a positive image and its use aids activities.Cohen-Mansfield Werner (1997) interaction while providing a sensory experience.It compared three types of intervention for people with also seems to be well tolerated in comparison with abnormal vocalisations,and found that music neuroleptic or sedative medication.The two main therapy significantly reduced the behaviour.More essential oils used in aromatherapy for dementia recently,a study by Gerdner (2000)found a are extracted from lavender and melissa balm.They significant reduction in agitation in people with also have the advantage that there are several routes dementia who were played an individualised of administration such as inhalation,bathing. programme of music as opposed to traditional massage and topical application in a cream.This relaxation music. means that the therapy can be targeted at individuals with different behaviours:inhalation may be more Activity therapy effective than massage for a person with restless- ness,for instance.There have been some positive Activity therapy involves a rather amorphous group results from recent controlled trials which have of recreations such as dance,sport and drama.It shown significant reductions in agitation,with has been shown that physical exercise can have a excellent compliance and tolerability (e.g.see number of health benefits for people with dementia, Ballard et al,2002).[An article on the use of for example reducing the number of falls and aromatherapy in dementia (Holmes Ballard,2004) improving mental health and sleep(King et al,1997) will appear in the next issue of APT.Ed.I and improving their mood and confidence (Young Dinan.1994).In addition.Alessi et al(1999)found Other therapies in a small-scale controlled study that daytime exercise helped to reduce daytime agitation and Two therapies worthy of mention in this section are night-time restlessness.An interesting approach to bright-light therapy and multisensory approaches. dance therapy is described by Perrin (1998),who Both of these have received some research attention employed a form of dance known as'jabadeo'.which and have demonstrated positive outcomes.For involves no prescriptive steps or motions but allows example,bright-light therapy has been increasingly the participants to engage with each other in used in an attempt to improve fluctuations in diurnal interactive movements.It is relevant to note that this rhythms that may account for night-time disturances may also fulfil a need for non-sexual physical contact and 'sundown syndrome'(recurring confusion or which many people with dementia find soothing. agitation in the late afternoon or early evening) in people with dementia.Three recent controlled Complementary therapy trials have been published with some evidence for improving restlessness and with particular benefit The Mental Health Foundation recently conducted for sleep disturbances (e.g.see Haffmanns et al, a study into the use of complementary therapies in 2001). the field of mental health that included their use in Multisensory approaches usually involve using dementia.From this work,it was evident that a a room designed to provide several types of sensory number of different therapies were being employed, stimulation such as light(often in the form of fibre for example massage,reflexology.reiki,therapeutic optics which can move and be flexible),texture 174 Advances in Psychiatric Treatment(2004).vol.10.http://apt.rcpsych.org/
174 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ Douglas et al/Woods & Allan 1999). Activities such as drawing and painting are thought to provide individuals with the opportunity for self-expression and the chance to exercise some choice in terms of the colours and themes of their creations. Music therapy Several studies have reported benefits gained by people with dementia from music therapy (Killick & Allan, 1999). The therapy may involve engagement in a musical activity (e.g. singing or playing an instrument), or merely listening to songs or music. Lord & Garner (1993) showed increases in levels of well-being, better social interaction and improvements in autobiographical memory in a group of nursing home residents who regularly had music played to them. Such improvements were not observed in a comparison group engaged in other activities. Cohen-Mansfield & Werner (1997) compared three types of intervention for people with abnormal vocalisations, and found that music therapy significantly reduced the behaviour. More recently, a study by Gerdner (2000) found a significant reduction in agitation in people with dementia who were played an individualised programme of music as opposed to traditional relaxation music. Activity therapy Activity therapy involves a rather amorphous group of recreations such as dance, sport and drama. It has been shown that physical exercise can have a number of health benefits for people with dementia, for example reducing the number of falls and improving mental health and sleep (King et al, 1997) and improving their mood and confidence (Young & Dinan, 1994). In addition, Alessi et al (1999) found in a small-scale controlled study that daytime exercise helped to reduce daytime agitation and night-time restlessness. An interesting approach to dance therapy is described by Perrin (1998), who employed a form of dance known as ‘jabadeo’, which involves no prescriptive steps or motions but allows the participants to engage with each other in interactive movements. It is relevant to note that this may also fulfil a need for non-sexual physical contact which many people with dementia find soothing. Complementary therapy The Mental Health Foundation recently conducted a study into the use of complementary therapies in the field of mental health that included their use in dementia. From this work, it was evident that a number of different therapies were being employed, for example massage, reflexology, reiki, therapeutic healing, herbal medicine and aromatherapy. The results of this survey have been reviewed by Wiles & Brooker (2003). In terms of effectiveness, it was evident that careful consideration was needed to identify what was meant by ‘effective’ (e.g. were the therapies aiming to improve cognitive abilities or levels of well-being?). In general, most of the complementary therapies have not received a great deal of empirical investigation. An exception to this is aromatherapy, which is described in more detail below. Aromatherapy Aromatherapy is one of the fastest growing of all the complementary therapies (Burns et al, 2002). It appears to have several advantages over the pharmacological treatments widely used for dementia. It has a positive image and its use aids interaction while providing a sensory experience. It also seems to be well tolerated in comparison with neuroleptic or sedative medication. The two main essential oils used in aromatherapy for dementia are extracted from lavender and melissa balm. They also have the advantage that there are several routes of administration such as inhalation, bathing, massage and topical application in a cream. This means that the therapy can be targeted at individuals with different behaviours: inhalation may be more effective than massage for a person with restlessness, for instance. There have been some positive results from recent controlled trials which have shown significant reductions in agitation, with excellent compliance and tolerability (e.g. see Ballard et al, 2002). [An article on the use of aromatherapy in dementia (Holmes & Ballard, 2004) will appear in the next issue of APT. Ed.] Other therapies Two therapies worthy of mention in this section are bright-light therapy and multisensory approaches. Both of these have received some research attention and have demonstrated positive outcomes. For example, bright-light therapy has been increasingly used in an attempt to improve fluctuations in diurnal rhythms that may account for night-time disturances and ‘sundown syndrome’ (recurring confusion or agitation in the late afternoon or early evening) in people with dementia. Three recent controlled trials have been published with some evidence for improving restlessness and with particular benefit for sleep disturbances (e.g. see Haffmanns et al, 2001). Multisensory approaches 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
Non-pharmacological interventions in dementia (cushions and vibrating pads),smell and sound. perspective is very suitable for people with dementia, The use of these resources is tailored to the as many of the behavioural difficulties encountered individual and therefore not all of the available emerge through one or more of the following forms of stimulation may be used in one session.A cognitive features:cognitive misinterpretations, description and discussion of multisensory therapy biases,distortions,erroneous problem-solving in psychiatric care has appeared in an earlier issue strategies and communication difficulties.In other of APT(Baillon et al.2002). words,many of the challenges posed by people with The use of such rooms with people with dementia dementia are due to their thinking style-the very has centred mainly on those with more severe thing that is addressed in CBT.Hence,CBT offers symptoms.A study by van Diepen et al(2002) a framework within which to understand the showed some positive effects on agitation,but the individual's distressing experiences,and this results failed to reach significance.Burns et al(2000) understanding allows the clinician to target have reviewed the increasing use of multisensory interventions more appropriately.In this sense,it is rooms.They concluded that the area was worthy of argued that CBT is a person-centred therapy. future research,but that the available evidence lacked scientific rigour. Conclusions Briefpsychotherapies Having reviewed many of the treatments currently Cognitive-behavioural therapy available,it is worth noting their common features. One striking thing is the move towards more person- Over the past 10 years there has been an increasing centred forms of care(Kitwood,1997).Within this interest in applying some of the brief therapeutic approach,greater attempts are made to understand frameworks such as cognitive-behavioural therapy the individual's experience of dementia and to (CBT)and interpersonal therapy to dementia.For employ strategies to improve the person's quality of example,Teri Gallagher-Thompson (1991) life.A further shared feature is the systemic reported positive findings from a clinical trial of perspective,that is,the need to work with systems CBT with people in the early stages of Alzheimer's (families,professional carers,organisations,etc.). disease.Individual and group CBT has also been Indeed,care staff and families are usually integral used by other researchers with some favourable to treatment strategies.They are essential in results (Kipling et al,1999). obtaining valid and reliable information and constructing appropriate formulations.Also,they Interpersonal therapy are key to conducting any interventions reliably.It Interpersonal therapy,as the name suggests. is evident,therefore,that training of carers (both examines the individual's distress within an professional and family)is an important part of most interpersonal context (Weissman et al,2000).In treatment programmes.In fact,one study study(Bird this sense,there is a great deal of overlap with the et al,2002)suggested that the most common person-centred work of Kitwood (1997)and Stokes interventions for psychological and behavioural (2000).It uses a specific framework in which the symptoms of dementia were not necessarily specific individual's distress is conceptualised through one therapies but working with carers or nursing home of four domains:interpersonal disputes;inter- staff to change the attitudes and behaviour of those personal/personality difficulties;bereavement;and in their care.Despite the relevance of this issue,there transitions/life events.Despite there being good remain relatively few high-quality studies in the area empirical evidence of the success of this form of (e.g.Marriott et al,2000).Clearly,training and treatment with older people (Miller Reynolds, support are important and worthy of further study: 2002).it has only recently been used with dementia future studies need to be large and also include (James et al,2003). follow-up methodologies. The field of dementia care is expanding.with an Limitations increasing number of articles on psychosocial interventions;to that extent the future looks Both CBT and interpersonal therapy have limi- promising.However,it is noted that there is a tations,particularly with severe dementia.Never- fundamental weakness within the current literature theless,owing to the fact that these therapies have that clearly requires addressing.This concerns the relatively simple conceptual models underpinning limited attention paid to process issues(i.e.details them,they have been shown to be helpful,even for outlining the mechanism of change underpinning severe cognitive impairment (ames et al,1999:James, the interventions).The available studies have been 2001).For example,James believes that a CBT good at presenting the contents of intervention Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/ 175
Non-pharmacological interventions in dementia Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 175 (cushions and vibrating pads), smell and sound. The use of these resources is tailored to the individual and therefore not all of the available forms of stimulation may be used in one session. A description and discussion of multisensory therapy in psychiatric care has appeared in an earlier issue of APT (Baillon et al, 2002). The use of such rooms with people with dementia has centred mainly on those with more severe symptoms. A study by van Diepen et al (2002) showed some positive effects on agitation, but the results failed to reach significance. Burns et al (2000) have reviewed the increasing use of multisensory rooms. They concluded that the area was worthy of future research, but that the available evidence lacked scientific rigour. Brief psychotherapies Cognitive–behavioural therapy Over the past 10 years there has been an increasing interest in applying some of the brief therapeutic frameworks such as cognitive–behavioural therapy (CBT) and interpersonal therapy to dementia. For example, Teri & Gallagher-Thompson (1991) reported positive findings from a clinical trial of CBT with people in the early stages of Alzheimer’s disease. Individual and group CBT has also been used by other researchers with some favourable results (Kipling et al, 1999). Interpersonal therapy Interpersonal therapy, as the name suggests, examines the individual’s distress within an interpersonal context (Weissman et al, 2000). In this sense, there is a great deal of overlap with the person-centred work of Kitwood (1997) and Stokes (2000). It uses a specific framework in which the individual’s distress is conceptualised through one of four domains: interpersonal disputes; interpersonal/personality difficulties; bereavement; and transitions/life events. Despite there being good empirical evidence of the success of this form of treatment with older people (Miller & Reynolds, 2002), it has only recently been used with dementia (James et al, 2003). Limitations Both CBT and interpersonal therapy have limitations, particularly with severe dementia. Nevertheless, owing to the fact that these therapies have relatively simple conceptual models underpinning them, they have been shown to be helpful, even for severe cognitive impairment (James et al, 1999; James, 2001). For example, James believes that a CBT perspective is very suitable for people with dementia, as many of the behavioural difficulties encountered emerge through one or more of the following cognitive features: cognitive misinterpretations, biases, distortions, erroneous problem-solving strategies and communication difficulties. In other words, many of the challenges posed by people with dementia are due to their thinking style – the very thing that is addressed in CBT. Hence, CBT offers a framework within which to understand the individual’s distressing experiences, and this understanding allows the clinician to target interventions more appropriately. In this sense, it is argued that CBT is a person-centred therapy. Conclusions Having reviewed many of the treatments currently available, it is worth noting their common features. One striking thing is the move towards more personcentred forms of care (Kitwood, 1997). Within this approach, greater attempts are made to understand the individual’s experience of dementia and to employ strategies to improve the person’s quality of life. A further shared feature is the systemic perspective, that is, the need to work with systems (families, professional carers, organisations, etc.). Indeed, care staff and families are usually integral to treatment strategies. They are essential in obtaining valid and reliable information and constructing appropriate formulations. Also, they are key to conducting any interventions reliably. It is evident, therefore, that training of carers (both professional and family) is an important part of most treatment programmes. In fact, one study study (Bird et al, 2002) suggested that the most common interventions for psychological and behavioural symptoms of dementia were not necessarily specific therapies but working with carers or nursing home staff to change the attitudes and behaviour of those in their care. Despite the relevance of this issue, there remain relatively few high-quality studies in the area (e.g. Marriott et al, 2000). Clearly, training and support are important and worthy of further study; future studies need to be large and also include follow-up methodologies. The field of dementia care is expanding, with an increasing number of articles on psychosocial interventions; to that extent the future looks promising. However, it is noted that there is a fundamental weakness within the current literature that clearly requires addressing. This concerns the limited attention paid to process issues (i.e. details outlining the mechanism of change underpinning the interventions). The available studies have been good at presenting the contents of intervention
Douglas et al/Woods programmes,but usually fail to outline how the Feil.N.(1967)Group therapy in a home for the aged. interventions were conducted (communication Gerontologist,7(1).192-195. Finkel,S.I.,Costa de Silva,J..Cohen,G..et al (1996) strategies,interpersonal style,feedback mechan. Behavioural and psychological signs and symptoms of isms,staff training issues).Indeed,if these issues dementia:a consensus statement on current knowledge were better delineated,it would help therapists and implications for research and treatment.International Journal of Psychogeriatrics.8.497-500. develop,refine and improve the manner in which Gerdner.L.(2000)Effects of individualized versus classical they implement their treatment programmes (ames 'relaxation"music on the frequency of agitation in elderly etal,2003). persons with Alzheimer's disease and related disorders. International Psychogeriatrics,12,49-65 Gibson,F.(1994)What can reminiscence contribute to people with dementia?In Reminiscence Reviewed:Evaluations. References Achievements.Perspectives (ed.J.Bornat).pp.46-60. Buckingham:Open Universitv Press. Allen-Burge.R..Stevens,A.Burgio.L.(1999)Effective Goudie,F.Stokes.G.(1989)Understanding confusion. behavioural interventions for decreasing dementia-related Nursing Times,85,35-37. challenging behaviour in nursing homes.International Haffmanns,P.M..Sival,R.C..Lucius,S.A..et al(2001) Journal of Geriatric Psychiatry.14.213-228. Bright light therapy and melatonin in motor restless Alessi,C..Yoon.E.,Schnelle.J.,et al (1999)A randomised trial behaviour in dementia:a placebo-controlled study. of a combined physical activity and environment intervention International Journal of Geriatric Psychiatry,16.106-110. in nursing home residents:do sleep and agitation improve? Hitch,S.(1994)Cognitive therapy as a tool for the caring Journal of the American Geriatrics Society,47.784-791 elderly confused person.Journal of Clinical Nursing.3.49- Baillon.S..van Diepen.E.Prettyman.R.(2002)Multi- 55. sensory therapy in psychiatric care.Advances in Psychiatric Holden.U.P.Woods.R.T.(1995)Positive Approaches to Treatment.8.444-450. Dementia Care (3rd edn).Edinburgh:Churchill Livingstone. Baines.S..Saxby.P.&Ehlert.K.(1987)Reality orientation and Holmes,C.Ballard,C.(2004)Aromatherapy in dementia reminiscence therapy:a controlled cross-over study of elderly Advances in Psychiatric Treatment,10,in pre confused people.British Journal of Psychiatry.151,222-231 James.I.(2001)Psychological therapies and approaches in Ballard,C. G.O'Brien,J.T.(1999)Pharmacological dementia.In Dementia:Management of Behavioural and treatment of behavioural and psychological signs in Psychological Symptoms (eds C.G.Ballard,J.O'Brien.I. Alzheimer's disease:how good is the evidence for current James,et al).Oxford:Oxford University Press. pharmacological treatments?BM.319.138-139. James.I..Kendell.K.Reichelt,F.K.(1999)Using a cognitive Ballard,C.G..O'Brien.J..James,I..et al (2001)Dementia: rationale to conceptualise anxiety in people with dementia. Management of Behavioural and Psychological Symptoms Behavioural and Cognitive Psychotherapy.27,345-351. Oxford:Oxford University Press. James,I.Powell,I Kendell.K.(2003)A cognitive perspective Ballard,C.G..O'Brien,J.,Reichelt,K.,et al (2002)Aroma on training in care homes.Journal of Dementia Care,11,22- therapy as a safe and effective treatment for the 24 management of agitation in severe dementia:the results of Killick,J.Allan,K.(1999)The arts in dementia care:tapping a double blind,placebo controlled trial.Journal of Clinical a rich resource.Journal of Dementia Care.7.35-38. Psychiatry.63,553-558. King.A..Oman.R..Brassington.G..et al (1997)Moderate Bird,M..Llewellyn-Jones,R.,Smithers,H..et al (2002) intensity exercise and self-rated quality of sleep in older Psychosocial Approaches to Challenging Behaviour in Dementia: adults.A randomised controlled trial.JAMA.277,32-37. A Controlled Trial.Report to the Commonwealth Department Kipling.T..Bailey,M.Charlesworth,G.(1999)The feasibility of Health and Ageing.Canberra:CDHA. of a cognitive behavioural therapy group for men with a Bleathman,C.Morton.I.(1988)Validation therapy and the mild/moderate cognitive impairment. Behavioural and demented elderly.Journal of Advanced Nursing.13.511-514. Cognitive Psychotherapy.27.189-193. Burgio,L.Fisher,S.(2000)Application of psychosocial Kitwood,T.(1997)Dementia Reconsidered:The Person Comes interventions for treating behavioural and psychological First.Buckingham:Open University Press. symptoms of dementia.International Psychogeriatrics,12 La Vigna,G.Donnellan,A.(1986)Alternative to Punishment: (suppl..1),351-358. Solving Behaviour Problems with Non-aversive Strategies.New Burns.I..Cox.H.Plant,H.(2000)Leisure or therapeutics? York:Irvington. Snoezelen and the care of older persons with dementia Lord,T.Garner.E.(1993)Effects of music on Alzheimer International Journal of Nursing Practice,6.118-126 patients.Perceptual and Motor Skills,76.451-455. Burns.A..Byrne,J.,Ballard,C..et al(2002)Sensory stimulation Margallo-Lana.M.,Swann,A.,O'Brien,J.,et al (2001) in dementia.An effective option for managing behavioural Prevalence and pharmacological management of behav- problems..BM0.325,1312-1313 ioural and psychological symptoms amongst dementia Cohen-Mansfield,J.(2000)Use of patient characteristics to sufferers living in care environments.International Journal of determine non-pharmacologic interventions for behavioural Geriatric Psychiatry.16.39-44. and psychological symptoms of dementia.International Marriott,A..Donaldson.C. Tarrier.N. etal(2000) Psychogeriatrics,12 (suppl.1).373-380. Effectiveness of cognitive-behavioural family intervention Cohen-Mansfield.J.Werner,P.(1997)Management of in reducing the burden of care in carers of patients with verbally disruptive behaviors in nursing home residents. Alzheimer's disease.British Journal of Psychiatry,176.557- Journals of Gerontology Series A-Biological Sciences and Medical 562. Sciences,52.369-377. Marshall,M.Hutchinson,S.(2001)Journal of Advanced Cohen-Mansfield,J..Marx,M.Werner,P.(1992)Agitation in Nursing.35.488-496. elderly persons:an integrative report of findings in a nursing McShane,R.,Keene,J..Gedling.K.,et al (1997).Do neuroleptic home.International Psychogeriatrics,4 (suppl.4),221-240. drugs hasten cognitive decline in dementia?Prospective Emerson.E.(1998)Working with people with challenging study with necropsy follow-up.BM,314,211-212 behaviour.In Clinical Psychology and People with Intellectual Meares.S.Draper,B.(1999)Treatment of vocally disruptive Disabilities (eds E.Emerson,C.Hatton,J.Bromley,et al). behaviour of multifactorial aetiology.International Journal Pp.127-153.Chichester:John Wiley Sons. of Geriatric Psychiatry,14.285-290. Emerson.E.Thompson,S..Reeves,D..etal (1995)Descriptive Miller.M.Reynolds.C.(2002)Interpersonal psychotherapy. analysis of multiple response topographies of challenging In Psychological Therapies with Older People:Developing behaviour across two settings.Research in Developmental Treatments for Effective Practice (eds J.Hepple,P.Pearce, Disabilities,16.301-329. G.Wilkinson),pp.103-127.Hove:Brunner-Routledge 176 Advances in Psychiatric Treatment(2004).vol.10.http://apt.rcpsych.org/
176 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ Douglas et al/Woods programmes, but usually fail to outline how the interventions were conducted (communication strategies, interpersonal style, feedback mechanisms, staff training issues). Indeed, if these issues were better delineated, it would help therapists develop, refine and improve the manner in which they implement their treatment programmes (James et al, 2003). References Allen-Burge, R., Stevens, A. & Burgio, L. (1999) Effective behavioural interventions for decreasing dementia-related challenging behaviour in nursing homes. International Journal of Geriatric Psychiatry, 14, 213–228. Alessi, C., Yoon, E., Schnelle, J., et al (1999) A randomised trial of a combined physical activity and environment intervention in nursing home residents: do sleep and agitation improve? Journal of the American Geriatrics Society, 47, 784–791. Baillon, S., van Diepen, E. & Prettyman, R. (2002) Multisensory therapy in psychiatric care. Advances in Psychiatric Treatment, 8, 444–450. Baines, S., Saxby, P. & Ehlert, K. (1987) Reality orientation and reminiscence therapy: a controlled cross-over study of elderly confused people. British Journal of Psychiatry, 151, 222–231. Ballard, C. G. & O’Brien, J. T. (1999) Pharmacological treatment of behavioural and psychological signs in Alzheimer’s disease: how good is the evidence for current pharmacological treatments? BMJ, 319, 138–139. Ballard, C. G., O’Brien, J., James, I., et al (2001) Dementia: Management of Behavioural and Psychological Symptoms. Oxford: Oxford University Press. Ballard, C. G., O’Brien, J., Reichelt, K., et al (2002) Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double blind, placebo controlled trial. Journal of Clinical Psychiatry, 63, 553–558. Bird, M., Llewellyn-Jones, R., Smithers, H., et al (2002) Psychosocial Approaches to Challenging Behaviour in Dementia: A Controlled Trial. Report to the Commonwealth Department of Health and Ageing. Canberra: CDHA. Bleathman, C. & Morton, I. (1988) Validation therapy and the demented elderly. Journal of Advanced Nursing, 13, 511–514. Burgio, L. & Fisher, S. (2000) Application of psychosocial interventions for treating behavioural and psychological symptoms of dementia. International Psychogeriatrics, 12, (suppl. 1), 351–358. Burns, I., Cox, H. & Plant, H. (2000) Leisure or therapeutics? Snoezelen and the care of older persons with dementia. International Journal of Nursing Practice, 6, 118–126. Burns, A., Byrne, J., Ballard, C., et al (2002) Sensory stimulation in dementia. An effective option for managing behavioural problems. BMJ, 325, 1312–1313. Cohen-Mansfield, J. (2000) Use of patient characteristics to determine non-pharmacologic interventions for behavioural and psychological symptoms of dementia. International Psychogeriatrics, 12 (suppl. 1), 373–380. Cohen-Mansfield, J. & Werner, P. (1997) Management of verbally disruptive behaviors in nursing home residents. Journals of Gerontology Series A – Biological Sciences and Medical Sciences, 52, 369–377. Cohen-Mansfield, J., Marx, M. & Werner, P. (1992) Agitation in elderly persons: an integrative report of findings in a nursing home. International Psychogeriatrics, 4 (suppl. 4), 221–240. Emerson, E. (1998) Working with people with challenging behaviour. In Clinical Psychology and People with Intellectual Disabilities (eds E. Emerson, C. Hatton, J. Bromley, et al), pp. 127–153. Chichester: John Wiley & Sons. Emerson, E., Thompson, S., Reeves, D., et al (1995) Descriptive analysis of multiple response topographies of challenging behaviour across two settings. Research in Developmental Disabilities, 16, 301–329. Feil, N. (1967) Group therapy in a home for the aged. Gerontologist, 7(1), 192–195. Finkel, S. I., Costa de Silva, J., Cohen, G., et al (1996) Behavioural and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment. International Journal of Psychogeriatrics, 8, 497–500. Gerdner, L. (2000) Effects of individualized versus classical “relaxation” music on the frequency of agitation in elderly persons with Alzheimer’s disease and related disorders. International Psychogeriatrics, 12, 49–65. Gibson, F. (1994) What can reminiscence contribute to people with dementia? In Reminiscence Reviewed: Evaluations, Achievements, Perspectives (ed. J. Bornat), pp. 46–60. Buckingham: Open University Press. Goudie, F. & Stokes, G. (1989) Understanding confusion. Nursing Times, 85, 35–37. Haffmanns, P. M., Sival, R. C., Lucius, S. A., et al (2001) Bright light therapy and melatonin in motor restless behaviour in dementia: a placebo-controlled study. International Journal of Geriatric Psychiatry, 16, 106–110. Hitch, S. (1994) Cognitive therapy as a tool for the caring elderly confused person. Journal of Clinical Nursing, 3, 49– 55. Holden, U. P. & Woods, R. T. (1995) Positive Approaches to Dementia Care (3rd edn). Edinburgh: Churchill Livingstone. Holmes, C. & Ballard, C. (2004) Aromatherapy in dementia. Advances in Psychiatric Treatment, 10, in press. James, I. (2001) Psychological therapies and approaches in dementia. In Dementia: Management of Behavioural and Psychological Symptoms (eds C. G. Ballard, J. O’Brien, I. James, et al). Oxford: Oxford University Press. James, I., Kendell, K. & Reichelt, F. K. (1999) Using a cognitive rationale to conceptualise anxiety in people with dementia. Behavioural and Cognitive Psychotherapy, 27, 345–351. James, I., Powell, I. & Kendell, K. (2003) A cognitive perspective on training in care homes. Journal of Dementia Care, 11, 22– 24. Killick, J. & Allan, K. (1999) The arts in dementia care: tapping a rich resource. Journal of Dementia Care, 7, 35–38. King, A., Oman, R., Brassington, G., et al (1997) Moderate intensity exercise and self-rated quality of sleep in older adults. A randomised controlled trial. JAMA, 277, 32–37. Kipling, T., Bailey, M. & Charlesworth, G. (1999) The feasibility of a cognitive behavioural therapy group for men with a mild/moderate cognitive impairment. Behavioural and Cognitive Psychotherapy, 27, 189–193. Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press. La Vigna, G. & Donnellan, A. (1986) Alternative to Punishment: Solving Behaviour Problems with Non-aversive Strategies. New York: Irvington. Lord, T. & Garner, E. (1993) Effects of music on Alzheimer patients. Perceptual and Motor Skills, 76, 451–455. Margallo-Lana, M., Swann, A., O’Brien, J., et al (2001) Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments. International Journal of Geriatric Psychiatry, 16, 39–44. Marriott, A., Donaldson, C., Tarrier, N., et al (2000) Effectiveness of cognitive–behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer’s disease. British Journal of Psychiatry, 176, 557– 562. Marshall, M. & Hutchinson, S. (2001) Journal of Advanced Nursing, 35, 488–496. McShane, R., Keene, J., Gedling, K., et al (1997). Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow-up. BMJ, 314, 211–212. Meares, S. & Draper, B. (1999) Treatment of vocally disruptive behaviour of multifactorial aetiology. International Journal of Geriatric Psychiatry, 14, 285–290. Miller, M. & Reynolds, C. (2002) Interpersonal psychotherapy. In Psychological Therapies with Older People: Developing Treatments for Effective Practice (eds J. Hepple, P. Pearce, & G. Wilkinson), pp. 103–127. Hove: Brunner-Routledge
Non-pharmacological interventions in dementia Mitchell.G.J.(1987)An Analysis of the Communication Process 2 Pharmacological treatments of dementia: and Content with Confused Elderly Clients during Validation Therapy.MA Thesis.Toronto:University of Toronto.School a can have many unwanted side-effects of Nursing. b are usually well prescribed and monitored Moniz-Cook.E,Agar.S..Silver,M..etal(1998)Can staff training c are used excessively in many care facilities reduce behavioural problems in residential care for the elderly d should not be used in treatment of BPSD mentally ill?International Journal of Geriatric Psychiatry,13 currently include the common use of neuroleptics to 149-158. Neal,M.&Briggs.M.(2002)Validation therapy for dementia. treat non-cognitive symptoms Cochrane Library,issue 3.Oxford:Update Software. O'Donovan,S.(1993)The memory lingers on.Elderly Care.5. 3 When discussing non-cognitive symptoms of 27-31. dementia: Perrin.T.(1998)Lifted into a world of rhythm and melody. Journal of Dementia Care.6.22-24. a memory problems and language disorders are Schultz.R.Williamson.G.H.(1991)A 2-year longitudinal common non-cognitive symptoms of dementia study of depression among Alzheimer's caregivers b the terms behavioural and psychological symp- Psychology and Aging.6,569-578. toms of dementia and challenging behaviours are Spector.A..Orrell,M.,Davies.S..et al (2001)Can reality synonymous orientation be rehabilitated?Development and piloting of one is solely talking about disruptive and agitated an evidence-based programme of cognition-based therapies for people with dementia.Neuropsychological Rehabilitation. behaviours 11,377-397. d neither psychological nor pharmacological treat- Spector,A..Orrell,M.,Davies,S..et al(2002a)Reality orientation ments seem to be effective for dementia.Cochrane Library,issue 3.Oxford:Update Software. e a non-pharmacological perspective would tend to Spector.A..Orrell,M..Davies,S.,et al (2002b)Reminiscence view a problematic behaviour as a manifestation of therapy for dementia.Cochrane Library,issue 3.Oxford: an underlying 'unmet'need. Update Software. Stokes,G.(2000)Challenging Behaviour in Dementia.Bicester: 4 A person with dementia: Speechmark. can be offered a number of different forms of non- Teri.L.Gallagher-Thompson,D.(1991)Cognitive- pharmacological intervention behavioural interventions for treatment of depression in Alzheimer's patients.Gerontologist,31.413-416. 6 can only be helped in the early stages of the dementia Van Diepen,E..Baillon,S.,Redman,J..et al (2002)A pilot C requires a moderate degree of intellectual insight in study of the physiological and behavioural effects of order to benefit from the non-pharmacological Snoezelen in dementia.British Journal of Occupational Therapy. treatments 65(2).61-66. Weissman,M..Markowitz.J.Klerman.G.(2000) d can be helped by unmet needs analysis.in which the Comprehensive Guide to Interpersonal Therapy.New York:Basic therapist identifies the patient's potential needs Books. e is unable to engage in the standard forms of Wiles,A.Brooker.D.(2003)Complementary therapies in psychotherapy (e.g.CBT.interpersonal therapy). dementia care.Journal of Dementia Care,11,31-36. Woods,R.T.(1999)Psychological Problems of Ageing.Chichester. John Wiley and Sons. 5 When employing non-pharmacological treatments: Young.A.Dinan,S.(1994)ABC of sports medicine.Fitness carers and/or staff should be willing to work/help for older people.BM/.309.331-334. with the treatment regimen b they should be used as an adjunct to pharmacological treatments Multiple choice questions c carers and/or staff may require both training and support in order to undertake the treatments 1 Non-pharmacological treatments for dementia: effectively a can be effective d improvements may occur across a range of abilities b should always be used as a second line of treatment (e.g.orientation,sleep,quality of life) to medication e one should always try to orient individuals with c aim to improve people's cognitive abilities dementia to what is happening in the present,so that d require the cooperation of staff they can engage in meaningful conversations and e are becoming increasingly well researched. interactions with others. MCQ answers 1 3 4 5 a T a T a F a T a T bF bF bF bF bF T cF c T d T dF dF dT dT e T e T eT e F e F Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/ 177
Non-pharmacological interventions in dementia Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 177 Mitchell, G. J. (1987) An Analysis of the Communication Process and Content with Confused Elderly Clients during Validation Therapy. MA Thesis. Toronto: University of Toronto, School of Nursing. Moniz-Cook, E., Agar, S., Silver, M., et al (1998) Can staff training reduce behavioural problems in residential care for the elderly mentally ill? International Journal of Geriatric Psychiatry, 13, 149–158. Neal, M. & Briggs, M. (2002) Validation therapy for dementia. Cochrane Library, issue 3. Oxford: Update Software. O’Donovan, S. (1993) The memory lingers on. Elderly Care, 5, 27–31. Perrin, T. (1998) Lifted into a world of rhythm and melody. Journal of Dementia Care, 6, 22–24. Schultz, R. & Williamson, G. H. (1991) A 2-year longitudinal study of depression among Alzheimer’s caregivers. Psychology and Aging, 6, 569–578. Spector, A., Orrell, M., Davies, S., et al (2001) Can reality orientation be rehabilitated? Development and piloting of an evidence-based programme of cognition-based therapies for people with dementia. Neuropsychological Rehabilitation, 11, 377–397. Spector, A., Orrell, M., Davies, S., et al (2002a) Reality orientation for dementia. Cochrane Library, issue 3. Oxford: Update Software. Spector, A., Orrell, M., Davies, S., et al (2002b) Reminiscence therapy for dementia. Cochrane Library, issue 3. Oxford: Update Software. Stokes, G. (2000) Challenging Behaviour in Dementia. Bicester: Speechmark. Teri, L. & Gallagher-Thompson, D. (1991) Cognitive– behavioural interventions for treatment of depression in Alzheimer’s patients. Gerontologist, 31, 413–416. Van Diepen, E., Baillon, S., Redman, J., et al (2002) A pilot study of the physiological and behavioural effects of Snoezelen in dementia. British Journal of Occupational Therapy, 65(2), 61–66. Weissman, M., Markowitz, J. & Klerman, G. (2000) Comprehensive Guide to Interpersonal Therapy. New York: Basic Books. Wiles, A. & Brooker, D. (2003) Complementary therapies in dementia care. Journal of Dementia Care, 11, 31–36. Woods, R. T. (1999) Psychological Problems of Ageing. Chichester: John Wiley and Sons. Young, A. & Dinan, S. (1994) ABC of sports medicine. Fitness for older people. BMJ, 309, 331–334. Multiple choice questions 1 Non-pharmacological treatments for dementia: a can be effective b should always be used as a second line of treatment to medication c aim to improve people’s cognitive abilities d require the cooperation of staff e are becoming increasingly well researched. MCQ answers 12345 aT aT aF aT aT bF bF bF bF bF cF cT cF cF cT dT dF dF dT dT eT eT eT eF eF 2 Pharmacological treatments of dementia: a can have many unwanted side-effects b are usually well prescribed and monitored c are used excessively in many care facilities d should not be used in treatment of BPSD e currently include the common use of neuroleptics to treat non-cognitive symptoms. 3 When discussing non-cognitive symptoms of dementia: a memory problems and language disorders are common non-cognitive symptoms of dementia b the terms behavioural and psychological symptoms of dementia and challenging behaviours are synonymous c one is solely talking about disruptive and agitated behaviours d neither psychological nor pharmacological treatments seem to be effective e a non-pharmacological perspective would tend to view a problematic behaviour as a manifestation of an underlying ‘unmet’ need. 4 A person with dementia: a can be offered a number of different forms of nonpharmacological intervention b can only be helped in the early stages of the dementia c requires a moderate degree of intellectual insight in order to benefit from the non-pharmacological treatments d can be helped by unmet needs analysis, in which the therapist identifies the patient’s potential needs e is unable to engage in the standard forms of psychotherapy (e.g. CBT, interpersonal therapy). 5 When employing non-pharmacological treatments: a carers and/or staff should be willing to work/help with the treatment regimen b they should be used as an adjunct to pharmacological treatments c carers and/or staff may require both training and support in order to undertake the treatments effectively d improvements may occur across a range of abilities (e.g. orientation, sleep, quality of life) e one should always try to orient individuals with dementia to what is happening in the present, so that they can engage in meaningful conversations and interactions with others
Douglas et al/Woods INVITED COMMENTARY ON Non-pharmacological interventions in dementia In managing the behavioural and psychological Need for recognition of anxiety symptoms of dementia(BPSD),clinical guidelines (Howard et al,2001)and good clinical practice and depression as key challenges recommend that pharmacological interventions in dementia care be used only after other,non-pharmacological, methods have been tried.In the real world,perhaps The authors'comments on brief psychotherapies especially in care homes,neuroleptic medication is serve as a reminder of the importance of responding likely to be prescribed and continued,in many cases more actively to the well-documented high levels indefinitely.This necessarily selective review by of anxiety and depression symptoms shown by Douglas and his colleagues perhaps illustrates some people with dementia (Ballard et al,1996a,b).It is of the obstacles that must be addressed if the worthy an obvious step to apply well-established psycho- intention to place less reliance on the illusory quick- logical therapies such as cognitive-behavioural fix of the tranquilliser prescription is ever to become therapy for depression(Scholey Woods,2003) a reality(Douglas et al,2004,this issue).The authors and relaxation for anxiety (Suhr et al,1999)to have identified a mixed bag of therapies with,at people in the early stages of dementia who display best,modest evidence for any efficacy,and which such symptoms;there is now no doubt regarding raise many issues regarding the feasibility of their the feasibility of such an approach,and one study widespread application. successfully utilised family carers as therapists (Teri et al,1997).More challenging are those people with severe dementia who have comorbid anxiety Need for clear treatment aims and depression;this is where some of the alterna- tive therapies and activities may have most to The various therapies described have a range of contribute. therapeutic goals,not always explicitly stated by those responsible for their development.Reality orientation,for example,has had a clear focus on BPSD v.challenging behaviour? cognition,particularly orientation.After falling from favour,largely through insensitive appli- The difference in terminology noted by Douglas et al cation,it has recently been adapted and revived as reflects a fundamental difference in conceptual- 'cognitive stimulation'(Woods,2002).In a recent isation.which.if not addressed.could stifle the trial,the changes in cognitive function were of the development of effective non-pharmacological same order of magnitude as those reported in trials approaches.In general,clinical psychologists prefer of acetylcholinesterase inhibitors (Spector et al, (although they are not completely happy with this) 2003).In its new form,it is associated with to talk of behaviour that challenges,because of its improvements in quality of life,but there is no implicit reminder that the problem lies in part with suggestion that it would,or should,affect BPSD. our reaction to the behaviour,which of itself may Reminiscence work has had a variety of aims, not present a problem to the person with dementia. plausibly spanning both cognition (autobio- Challenging behaviour is a function of a particular graphical memory)and mood.Validation therapy. care environment;in a different care setting,the with its emphasis on the emotional content of behaviour in question may not be elicited,or may communication,similarly should have its main not be viewed as a problem by those providing care. impact on affect.The 'alternative'therapies also The association between carer strain and difficult have a range of potential aims,although the behaviour is often noted,but rarely is the possibility putative impact of aromatherapy and music entertained that a stressed carer behaves in ways therapy on arousal levels is of particular interest, that elicit more difficult behaviour from the person if this is seen as a possible factor in behaviours with dementia (Woods.2001).The implication is a described as agitated. difficult one;rather than prescribing a'therapy', 178 Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/
178 Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ Douglas et al/Woods In managing the behavioural and psychological symptoms of dementia (BPSD), clinical guidelines (Howard et al, 2001) and good clinical practice recommend that pharmacological interventions be used only after other, non-pharmacological, methods have been tried. In the real world, perhaps especially in care homes, neuroleptic medication is likely to be prescribed and continued, in many cases indefinitely. This necessarily selective review by Douglas and his colleagues perhaps illustrates some of the obstacles that must be addressed if the worthy intention to place less reliance on the illusory quickfix of the tranquilliser prescription is ever to become a reality (Douglas et al, 2004, this issue). The authors have identified a mixed bag of therapies with, at best, modest evidence for any efficacy, and which raise many issues regarding the feasibility of their widespread application. Need for clear treatment aims The various therapies described have a range of therapeutic goals, not always explicitly stated by those responsible for their development. Reality orientation, for example, has had a clear focus on cognition, particularly orientation. After falling from favour, largely through insensitive application, it has recently been adapted and revived as ‘cognitive stimulation’ (Woods, 2002). In a recent trial, the changes in cognitive function were of the same order of magnitude as those reported in trials of acetylcholinesterase inhibitors (Spector et al, 2003). In its new form, it is associated with improvements in quality of life, but there is no suggestion that it would, or should, affect BPSD. Reminiscence work has had a variety of aims, plausibly spanning both cognition (autobiographical memory) and mood. Validation therapy, with its emphasis on the emotional content of communication, similarly should have its main impact on affect. The ‘alternative’ therapies also have a range of potential aims, although the putative impact of aromatherapy and music therapy on arousal levels is of particular interest, if this is seen as a possible factor in behaviours described as agitated. Need for recognition of anxiety and depression as key challenges in dementia care The authors’ comments on brief psychotherapies serve as a reminder of the importance of responding more actively to the well-documented high levels of anxiety and depression symptoms shown by people with dementia (Ballard et al, 1996a,b). It is an obvious step to apply well-established psychological therapies such as cognitive–behavioural therapy for depression (Scholey & Woods, 2003) and relaxation for anxiety (Suhr et al, 1999) to people in the early stages of dementia who display such symptoms; there is now no doubt regarding the feasibility of such an approach, and one study successfully utilised family carers as therapists (Teri et al, 1997). More challenging are those people with severe dementia who have comorbid anxiety and depression; this is where some of the alternative therapies and activities may have most to contribute. BPSD v. challenging behaviour? The difference in terminology noted by Douglas et al reflects a fundamental difference in conceptualisation, which, if not addressed, could stifle the development of effective non-pharmacological approaches. In general, clinical psychologists prefer (although they are not completely happy with this) to talk of behaviour that challenges, because of its implicit reminder that the problem lies in part with our reaction to the behaviour, which of itself may not present a problem to the person with dementia. Challenging behaviour is a function of a particular care environment; in a different care setting, the behaviour in question may not be elicited, or may not be viewed as a problem by those providing care. The association between carer strain and difficult behaviour is often noted, but rarely is the possibility entertained that a stressed carer behaves in ways that elicit more difficult behaviour from the person with dementia (Woods, 2001). The implication is a difficult one; rather than prescribing a ‘therapy’, INVITED COMMENTARY ON Non-pharmacological interventions in dementia
Non-pharmacological interventions in dementia alternative or otherwise,some of our interventions et al,1999;Ballard et al,2002)or through the input have to involve changes in the attributions,attitudes of a multidisciplinary team in a family care and interactions of family carers and paid care context (Hinchliffe et al,1995).Further analysis workers.It is here,indeed,that a fuller under- development and evaluation of these intervention standing of the carer's cognitions and affect models is required,if non-pharmacological inter- regarding the person in their care,and also of their ventions are to take their proper place in the real behaviour in relation to other members of the care world of dementia care. system,will prove invaluable. References Need for individualised Ballard,C.G..Bannister,C.Oyebode,F.(1996a) Depression in dementia sufferers.International Journal of formulations Geriatric Psychiatry,11,507-515. Ballard.C..Boyle.A..Bowler.C..et al (1996b)Anxiety disorders in dementia sufferers.International Journal of Having identified symptoms such as agitation, Geriatric Psychiatry,11.987-990. aggression,wandering and the like,it is tempting to Ballard,C.,Powell,I.,James,I..et al(2002)Can psychiatric identify the most effective therapeutic approach for liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities? each.However,the same label may become attached International Journal of Geriatric Psychiatry.17.140-145. to quite different behaviours,requiring quite Brooker.D.J.R..Snape,M..Johnson.E.,et al (1997)Single different interventions.Add to this the person's case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia.British Journal unique social environment,their particular profile of Clinical Psychology,36,287-296 of physical health,their life history and so on,and Douglas,S..James.I.Ballard,C.(2004)Non-pharma it is clear that an individual assessment and analysis cological interventions in dementia.Advances in Psychiatric Treatment,10,171-177. of each person's situation is needed.Even if two Hinchliffe.A.C..Hyman.I.L..Blizard.B..et al (1995) people with dementia are both thought to be Behavioural complications of dementia-can they be showing agitation because of a high level of internal treated?International Journal of Geriatric Psychiatry.10.839- 847. arousal,what helps one may be quite different from Howard.R..Ballard.C..O'Brien.J..et al(2001)Guidelines what helps the other.One person's relaxing and for the management of agitation in dementia.International calming hand-massage may be another person's Journal of Geriatric Psychiatry.16.714-717. Proctor,R..Burns.A.,Stratton-Powell,H..et al (1999) invasion of personal space and confinement Behavioural management in nursing and residential (Brooker et al,1997).Evidence-based practice in homes:a randomised controlled trial.Lancet,354,26-29. dementia care entails establishing'what works for Scholey.K.A.Woods.B.T.(2003)A series of brief cognitive whom',rather than a standard approach;this may therapy interventions with people experiencing both dementia and depression:a description of techniques and require readiness to adopt a more empirical common themes.Clinical Psychology and Psychotherapy approach,using simple single-case designs,with 10,175-185. the person as their own control. Spector,A.,Thorgrimsen,L..Woods,B..et al (2003)Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia:randomised controlled trial.British Journal of Psychiatry.183.248-254 Implementing change Suhr.J.,Anderson,S.Tranel.D.(1999)Progressive muscle relaxation in the management of behavioural disturbance in Alzheimer's disease.Neuropsychological Rehabilitation. If it is indeed the case that effective non-pharma- 9.31-44. cological interventions must be based on individual Teri,L..Logsdon.R.G.,Uomoto,J.,et al (1997)Behavioral treatment of depression in dementia patients:a controlled assessment and formulation,with an understanding clinical trial.Journals of Gerontology Series B-Psychological of the role of the social environment in the Sciences and Social Sciences,52.P159-P166 development and maintenance of the problem, Woods.B.(2002)Editorial:Reality orientation:a welcome training alone,for family carers or for care-workers. return?Age and Ageing.31.155-156. Woods.R.T.(2001)Discovering the person with Alzheimer's will be of limited use.Input is also required from disease:cognitive,emotional and behavioural aspects. mental health professionals(including community Aging and Mental Health,5(suppl.1).S7-S16. mental health nurses and clinical psychologists,as well as psychiatrists)who have skills in dementia Bob Woods Professor of Clinical Psychology with Older care and the ability to work at a systemic level.Some People.University of Wales Bangor (Ardudwy.Holyhead models of how this might be achieved are already Road,Bangor,Gwynedd LL57 2PX.UK.E-mail:b.woods@ bangor.ac.uk),Co-Director of the Dementia Services being developed,for example through regular visits Development Centre Wales and Director of the Centre for to a care home by a mental health nurse (Proctor Social Policy Research and Development. Advances in Psychiatric Treatment(2004),vol.10.http://apt.rcpsych.org/ 179
Non-pharmacological interventions in dementia Advances in Psychiatric Treatment (2004), vol. 10. http://apt.rcpsych.org/ 179 alternative or otherwise, some of our interventions have to involve changes in the attributions, attitudes and interactions of family carers and paid careworkers. It is here, indeed, that a fuller understanding of the carer’s cognitions and affect regarding the person in their care, and also of their behaviour in relation to other members of the care system, will prove invaluable. Need for individualised formulations Having identified symptoms such as agitation, aggression, wandering and the like, it is tempting to identify the most effective therapeutic approach for each. However, the same label may become attached to quite different behaviours, requiring quite different interventions. Add to this the person’s unique social environment, their particular profile of physical health, their life history and so on, and it is clear that an individual assessment and analysis of each person’s situation is needed. Even if two people with dementia are both thought to be showing agitation because of a high level of internal arousal, what helps one may be quite different from what helps the other. One person’s relaxing and calming hand-massage may be another person’s invasion of personal space and confinement (Brooker et al, 1997). Evidence-based practice in dementia care entails establishing ‘what works for whom’, rather than a standard approach; this may require readiness to adopt a more empirical approach, using simple single-case designs, with the person as their own control. Implementing change If it is indeed the case that effective non-pharmacological interventions must be based on individual assessment and formulation, with an understanding of the role of the social environment in the development and maintenance of the problem, training alone, for family carers or for care-workers, will be of limited use. Input is also required from mental health professionals (including community mental health nurses and clinical psychologists, as well as psychiatrists) who have skills in dementia care and the ability to work at a systemic level. Some models of how this might be achieved are already being developed, for example through regular visits to a care home by a mental health nurse (Proctor et al, 1999; Ballard et al, 2002) or through the input of a multidisciplinary team in a family care context (Hinchliffe et al, 1995). Further analysis, development and evaluation of these intervention models is required, if non-pharmacological interventions are to take their proper place in the real world of dementia care. References Ballard, C. G., Bannister, C. & Oyebode, F. (1996a) Depression in dementia sufferers. International Journal of Geriatric Psychiatry, 11, 507–515. Ballard, C., Boyle, A., Bowler, C., et al (1996b) Anxiety disorders in dementia sufferers. International Journal of Geriatric Psychiatry, 11, 987–990. Ballard, C., Powell, I., James, I., et al (2002) Can psychiatric liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities? International Journal of Geriatric Psychiatry, 17, 140–145. Brooker, D. J. R., Snape, M., Johnson, E., et al (1997) Single case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia. British Journal of Clinical Psychology, 36, 287–296. Douglas, S., James, I. & Ballard, C. (2004) Non-pharmacological interventions in dementia. Advances in Psychiatric Treatment, 10, 171–177. Hinchliffe, A. C., Hyman, I. L., Blizard, B., et al (1995) Behavioural complications of dementia – can they be treated? International Journal of Geriatric Psychiatry, 10, 839– 847. Howard, R., Ballard, C., O’Brien, J., et al (2001) Guidelines for the management of agitation in dementia. International Journal of Geriatric Psychiatry, 16, 714–717. Proctor, R., Burns, A., Stratton-Powell, H., et al (1999) Behavioural management in nursing and residential homes: a randomised controlled trial. Lancet, 354, 26–29. Scholey, K. A. & Woods, B. T. (2003) A series of brief cognitive therapy interventions with people experiencing both dementia and depression: a description of techniques and common themes. Clinical Psychology and Psychotherapy, 10, 175–185. Spector, A., Thorgrimsen, L., Woods, B., et al (2003) Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial. British Journal of Psychiatry, 183, 248–254. Suhr, J., Anderson, S. & Tranel, D. (1999) Progressive muscle relaxation in the management of behavioural disturbance in Alzheimer’s disease. Neuropsychological Rehabilitation, 9, 31–44. Teri, L., Logsdon, R. G., Uomoto, J., et al (1997) Behavioral treatment of depression in dementia patients: a controlled clinical trial. Journals of Gerontology Series B – Psychological Sciences and Social Sciences, 52, P159–P166. Woods, B. (2002) Editorial: Reality orientation: a welcome return? Age and Ageing, 31, 155–156. Woods, R. T. (2001) Discovering the person with Alzheimer’s disease: cognitive, emotional and behavioural aspects. Aging and Mental Health, 5 (suppl. 1), S7–S16. Bob Woods Professor of Clinical Psychology with Older People, University of Wales Bangor (Ardudwy, Holyhead Road, Bangor, Gwynedd LL57 2PX, UK. E-mail: b.woods@ bangor.ac.uk), Co-Director of the Dementia Services Development Centre Wales and Director of the Centre for Social Policy Research and Development
