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 quick￾fix 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 appli￾cation, 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 (autobio￾graphical 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 psycho￾logical 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 alterna￾tive 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 conceptual￾isation, 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