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. 171Non-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 non￾cognitive 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 non￾pharmacological approaches before considering pharmacological interventions. All too often in practice, however, pharmaco￾logical 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 par￾ticular 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 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. 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@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