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References and conclusions

Psychosocial interventions

Brodaty H, Green A, Koschera A. Meta-Analysis of Psychosocial Interventions for Caregivers of People with Dementia. JAGS 51:657–664, 2003

Programs that involve the patients and their families and are more intensive and modified to caregivers’ needs may be more successful. Caregiver interventions can have effects on delaying nursing home admission, which for many is desirable. Unsuccessful interventions are short educational programs (beyond enhancement of knowledge); support groups alone, single interviews, and brief interventions or courses that were not supplemented with long-term contact do not work.

Chung JCC, Lai CKY. Snoezelen for dementia (Review). Cochrane Database Syst Rev. 2002;(4):CD003152

Owing to the limited data obtained from the two included RCTs, it is not feasible to draw a conclusion in this review about the efficacy of Snoezelen. Although the pooled results of the two studies did not demonstrate a signifcant result in favour of snoezelen, they independently demonstrated signifcant results in favour of snoezelen. Regarding the short-term effects, Kragt 1997's subjects presented significantly fewer behavioural problems (e.g. apathy, restlessness) during the snoezelen sessions than the control sessions. Baker 2001's subjects were more responsive to their surrounding environments immediately after the sessions.

From the practice perspective, snoezelen programmes demonstrate positive immediate outcomes in reducing maladaptive behaviours and promoting positive behaviours, suggesting that it should be considered as part of the general dementia care programme.

Clare L, Woods RT, Moniz Cook ED, Orrell M, Spector A. Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia (Review). Cochrane Database Syst Rev. 2003;(4):CD003260.

The present findings do not provide strong support for the use of cognitive training interventions for people with early-stage AD or vascular dementia, although these findings must be viewed with caution due to the limited number of RCTs available and to the methodological limitations identified, and further well-designed trials would help to provide more definitive evidence.

Due to a complete absence of RCTs evaluating an individualised cognitive rehabilitation approach, it is not possible at present to draw conclusions about the efficacy of individualised cognitive rehabilitation interventions for people with early-stage dementia, and further research is required in this area.

Cooke DD, McNally MCN, Mulligan KT, Harrison MJG, Newman SP. Psychosocial interventions for caregivers of people with dementia: a systematic review. Aging & Mental Health 2001; 5(2): 120–135

The studies reviewed here do show that it is possible to produce consistent improvements in caregivers’ knowledge of the care recipients’ illness, but knowledge appears unrelated to psychological and social outcomes. The findings of the review suggest that the inclusion of social components in interventions or a combination of social and cognitive components appears to be relatively effective in improving psychological well-being.

Forbes D, Morgan DG, Bangma J, Peacock S, Adamson J. Light Therapy for Managing Sleep, Behaviour, and Mood Disturbances in Dementia (Review) Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD003946.

There is insufficient evidence of the efficacy of light therapy in managing sleep, behaviour, cognition or mood disturbances associated with dementia. Available studies are of poor quality.

Heyn P, Abreu BC, Ottenbacher KJ. The Effects of Exercise Training on Elderly Persons With Cognitive Impairment and Dementia: A Meta-Analysis. Arch Phys Med Rehabil 2004 Vol 85

Exercise training increases fitness, physical function, cognitive function, and positive behavior in people with dementia and related cognitive impairments. Exercise was associated with statistically significant positive treatment effects in older patients with dementia and cognitive impairments. The meta-analysis results suggest a medium to large treatment effect for health-related physical fitness components, and an overall medium treatment effect for combined physical, cognitive, functional, and behavioral outcomes. The results provide preliminary evidence for the effectiveness of exercise treatments for persons with dementia and related cognitive impairments.

Lee H, Cameron M. Respite care for people with dementia and their carers. Cochrane Database Syst Rev. 2004;(2):CD004396

Results from three randomized controlled trials provided no evidence of any benefit of respite care for people with dementia or for their caregivers for any outcome including rates of institutionalization and caregiver burden. However, a host of methodological problems in available trials were identified. Further methodologically sound research is needed before any firm conclusions can be drawn. No meaningful conclusions for practice can be drawn with the available evidence.

Livingston G, Johnston K, Katona C, Lyketsos CG. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry. 2005 Nov;162(11):1996-2021.

Behavioral management techniques centered on individual patients’ behavior are generally successful for reduction of neuropsychiatric symptoms, and the effects of these interventions last for months, despite qualitative disparity. Psychoeducation intended to change caregivers’ behavior is effective, especially if it is provided in individual rather than group settings, and improvements in neuropsychiatric symptoms associated with these interventions are sustained for months. We therefore recommend these types of interventions. Music therapy and Snoezelen, and possibly some types of sensory stimulation, are useful treatments for neuropsychiatric symptoms during the session but have no longer-term effects. The cost or complexity of Snoezelen for such small benefit may be a barrier to its use. Specific types of staff education lead to reductions in behavioral symptoms and use of restraints and to improved affective states. Staff education is, however, heterogeneous, although instruction for staff in communication skills and enhancement of staff members’ knowledge about dementia may improve many outcomes related to neuropsychiatric symptoms. Teaching staff to use dementia-specific psychological therapies for which there is limited evidence of efficacy may not improve these outcomes.

Little evidence is available on the effectiveness of reminiscence therapy, but more positive evidence exists for cognitive stimulation therapy. Training for caregivers in behavioral management techniques had inconsistent outcomes but merits further study. The evidence for therapeutic activities is very mixed, and the study findings for these interventions are contradictory and inconclusive. Specialized dementia units were not consistently beneficial, but changing the environment visually and unlocking doors successfully reduced wandering in institutions. These promising interventions merit more study.

There is no convincing evidence that simulated presence interventions or reduced stimulation units are efficacious for neuropsychiatric symptoms. Reality orientation therapy, validation therapy, “admiral” nurses, and Montessori activities had no effect on neuropsychiatric symptoms.

Neal M, BartonWright P. Validation therapy for dementia. Cochrane Database of Systematic Reviews 2003, Issue 3. Art.No.: CD001394.

There is insufficient evidence from randomized trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment.

Pusey H, Richards D. A systematic review of the effectiveness of psychosocial interventions for carers of people with dementia. Aging & Mental Health 2001; 5(2): 107–119

The overall methodological quality of the studies was poor, particularly with regard to sample size, and methods of random allocation. Individualized interventions that utilized problem solving and behaviour management demonstrated the best evidence of effectiveness. This approach is also closest to the effective model of psychosocial interventions currently in use with other severe and enduring illnesses.

Price JD, Hermans DG, Grimley Evans J. Subjective barriers to prevent wandering of cognitively impaired people. Cochrane Database Syst Rev. 2000;(4):CD001932

There is no evidence so far that subjective barriers reduce wandering, and the possibility of harm (particularly psychological distress) cannot be excluded. If used, then subjective barriers should form part of a diverse approach to problem wandering, which may include the identification and definition of the problem in the individual, preventative activities such as exercise classes or occupational therapies, and improved communication between carer and wanderer.

Sörensen S, Pinquart M, Duberstein P. How Effective Are Interventions With Caregivers? An Updated Meta-Analysis. The Gerontologist. 2002; 42(3): 356–372

Interventions are, on average, successful in alleviating burden and depression, increasing general subjective well-being, and increasing caregiving ability/knowledge. The majority of these effects persist after an average of 7 months postintervention. Providing psychoeducational interventions, psychotherapy, and a combination of several of these interventions, as is done in multicomponent approaches, is most effective for improving caregiver well-being in the short term.

Teri L, McKenzie G, LaFazia D. Psychosocial Treatment of Depression in Older Adults with Dementia.Clin Psychol Sci Prac 12: 303–316, 2005

Using multiple techniques, including behavioral skill training, communication, social engagement, and sensory and environmental stimulation in a variety of settings, including long-term care and private homes, 7 of the 11 treatments demonstrated clear improvements in depression. In 6 studies, these improvements were maintained beyond the active treatment period. Commonalities across these programs included assessment strategies, individualisation of strategies, providing treatment in a one-on-one format, using multiple treatment components in a coordinated programmatic approach, and focusing on teaching caregivers to deliver treatments to the persons with dementia. Much of what caregivers were taught involved problem-solving disease difficulties and facilitating increased pleasant social interaction.

Thorgrimsen L, Spector A, Wiles A, Orrell M. Aroma therapy for dementia. Cochrane Database Syst Rev. 2003;(3):CD003150

Aroma therapy showed benefit on measures of agitation and neuropsychiatric symptoms for people with dementia in the only trial that contributed data to this review, but there were several methodological difficulties with this study. More well designed large-scale RCTs are needed before conclusions can be drawn on the effectiveness of aroma therapy. Additionally, several issues need to be addressed, such as whether different aroma therapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.

Verkaik R, van Weert JCM, Francke AL. The effects of psychosocial methods on depressed, aggressive and apathetic behaviors of people with dementia: a systematic review. Int J Geriatr Psychiatry 2005; 20: 301–314.

There is some evidence that Multi Sensory Stimulation/Snoezelen in a Multi Sensory Room reduces apathy in people in the later phases of dementia. There is scientific evidence, although limited, that Behavior Therapy–Pleasant Events and Behavior Therapy–Problem Solving reduce depression in people with probable Alzheimer’s disease who are living at home with their primary caregiver.

There is also limited evidence that Psychomotor Therapy Groups reduce aggression in a specific group of nursing home residents diagnosed with probable Alzheimer’s disease. The evidence comes from a maximum of two high quality RCTs that arrive at the same positive results.

Although the evidence for the effectiveness of some psychosocial methods is stronger than for others, overall the evidence remains quite modest and further research needs to be carried out.

Vink AC, Birks JS, Bruinsma MS, Scholten RJS. Music therapy for people with dementia (Review). Cochrane Database Syst Rev.2004;(3):CD003477

The methodological quality and the reporting of the included studies were too poor to draw any useful conclusions. Despite five studies claiming a favourable effect of music therapy in reducing problems in the behavioural, social, emotional, and cognitive domains we cannot endorse these claims owing to the poor quality of the studies.

Woods B, Spector A, Jones C, Orrell M, Davies S. Reminiscence therapy for dementia (Review). Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001120

The evidence-base for the effectiveness of reminiscence therapy continues to rest largely on descriptive and observational studies, with the few RCTs available being small, of relatively low quality and with some variation in outcome, perhaps related to the diverse forms of RT used. It is too early to provide any indication of the effectiveness of reminiscence therapy in comparison with other psychosocial interventions, such as validation therapy or music therapy.However, given its popularity with staff and participants, there is no reason not to continue with its further development and evaluation. The need for training, support and supervision for staff carrying out this work is emphasised in much of the RT literature.



Last Updated: Thursday 08 October 2009


  • Acknowledgements

    The EuroCoDe project received financial support from the European Commission. Neither the European Commission nor any person acting on its behalf is responsible for any use that might be made of the following information. Alzheimer Europe also gratefully acknowledges the support it received from Fondation Médéric Alzheimer for this project.
  • European Union
  • Fondation Médéric Alzheimer