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/ 173Non-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 high￾quality 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 motiv￾ation (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