Non-pharmacological interventions to treat behavioural disturbances

Abraha, I. et al. (2017) Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open. 7:e012759


Objective: To provide an overview of non-pharmacological interventions for behavioural and psychological symptoms in dementia (BPSD).

Design: Systematic overview of reviews.


Conclusions: A large number of non-pharmacological interventions for BPSD were identified. The majority of the studies had great variation in how the same type of intervention was defined and applied, the follow-up duration, the type of outcome measured, usually with modest sample size. Overall, music therapy and behavioural management techniques were effective for reducing BPSD.

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Psychosocial interventions delivered by care home staff to people with dementia

Rapaport, P. et al. (2017) BMJ Open. 7:e014177

Objectives: This review aims to understand what elements of psychosocial interventions are associated with improved outcomes for people with dementia to inform implementation in care homes.

Conclusions: Psychosocial interventions can improve outcomes for staff and residents with dementia in care homes; however, many trial results are limited. Synthesis of qualitative findings highlight core components of interventions that staff value and feel improve care. These findings provide useful evidence to inform the development of sustainable, effective psychosocial interventions in care homes.

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The use of non-pharmacological interventions for dementia behaviours in care homes

Backhouse, T. et al. (2016) Age Ageing. 45(6) pp.856-863

Background: Antipsychotic medications have been used to manage behavioural and psychological symptoms of dementia (BPSD). Due to the potential risks associated with these medications for people with dementia, non-pharmacological interventions (NPIs) have been recommended as safer alternatives. However, it is unknown if, or how, these interventions are used in care homes to help people experiencing BPSD.

Conclusions: There is a gap between rhetoric and practice with most NPIs in care homes used as social activities rather than as targeted interventions. If NPIs are to become viable alternatives to antipsychotic medications in care homes, further work is needed to embed them into usual care practices and routines. Training for care-home staff could also enable residents with high needs to gain better access to suitable activities.

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Perceptions vs. evidence:therapeutic substitutes for antipsychotics

Olivieri-Mui, B.L. et al. Aging & Mental Health. Published online: 12 Jan 2017


Objective: To compare differences between clinician perceptions of therapeutic substitutes for antipsychotics prescribed to patients with dementia in long term care (LTC) and published evidence.


Conclusion: Perceptions of LTC clinicians regarding substitutes for antipsychotics in LTC patients with dementia vary widely and are often discordant with published evidence.

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Reminiscence groups for people with dementia and their family carers: REMCARE trial

Collier, E. The Mental Elf Blog. Published online: 24 October 2016


Reminiscence groups are a popular activity for people with dementia. It is an interesting and pleasurable activity that encourages empathy, good relationships and social interaction between people with dementia and others.

The benefits of participating in reminiscence groups for people with dementia seems to have a reasonably good evidence base (Woods et al 2005; Huang et al 2015), but the trial reviewed here (Woods et al, 2016) aimed to investigate the effectiveness of running reminiscence groups including people with dementia and their family carer. It also examined the cost effectiveness of the intervention.

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Psychosocial interventions for people with dementia: An overview and commentary on recent developments

Oyebode, J.R. & Parveen, S. Dementia. Published online: 4 July 2016
Image source: Bill McConkey – Wellcome Images // CC BY-NC-ND 4.0

An influential review in 2010 concluded that non-pharmacological multi-component interventions have positive effects on cognitive functioning, activities of daily living, behaviour and mood of people with dementia. Our aim here is to provide an up-to-date overview of research into psychosocial interventions and their impact on psychosocial outcomes.

We focused on randomised controlled trials, controlled studies and reviews published between October 2008 and August 2015, since the earlier review. The search of PsychInfo, Medline and the Cochrane database of systematic reviews yielded 61 relevant articles, organised into four themes echoing key phases of the care pathway: Living at home with dementia (five reviews, eight studies), carer interventions (three reviews, four studies), interventions in residential care (16 reviews, 12 studies) and end-of-life care (three reviews, two studies), along with an additional group spanning community and institutional settings (six reviews, two studies).

Community findings suggested that appointment of dementia specialists and attention to case management can produce positive outcomes; physical therapies, cognitive training and modified cognitive behaviour therapy also had a range of benefits. There was more limited evidence of positive benefits for people with dementia through interventions with family carers. Thirty-two articles focused on the management of ‘behavioural symptoms’ through a range of interventions all of which had some evidence of benefit. Also a range of multi-component and specific interventions had benefits for cognitive, emotional and behavioural well-being of people with dementia in residential settings, as well as for quality of life. Overall, interventions tended to be short term with impact only measured in the short term.

We recommend further research on interventions to promote living well in the community post-diagnosis and to address end-of-life care. Development of psychosocial interventions would benefit from moving beyond the focus on control of behaviours to focus on wider aspects of life for people with dementia.

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Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews

Laver, K. et al. BMJ Open. 2016. 6:e010767


Objective: To summarise existing systematic reviews that assess the effects of non-pharmacological, pharmacological and alternative therapies on activities of daily living (ADL) function in people with dementia.

Design: Overview of systematic reviews.

Methods: A systematic search in the Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE and PsycInfo in April 2015. Systematic reviews of randomised controlled trials conducted in people with Alzheimer’s disease or dementia measuring the impact on ADL function were included. Methodological quality of the systematic reviews was independently assessed by two authors using the AMSTAR tool. The quality of evidence of the primary studies for each intervention was assessed using GRADE.

Results: A total of 23 systematic reviews were included in the overview. The quality of the reviews varied; however most (65%) scored 8/11 or more on the AMSTAR tool, indicating high quality. Interventions that were reported to be effective in minimising decline in ADL function were: exercise (6 studies, 289 participants, standardised mean difference (SMD) 0.68, 95% CI 0.08 to 1.27; GRADE: low), dyadic interventions (8 studies, 988 participants, SMD 0.37, 95% CI 0.05 to 0.69; GRADE: low) acetylcholinesterase inhibitors and memantine (12 studies, 4661 participants, donepezil 10 mg SMD 0.18, 95% CI 0.03 to 0.32; GRADE: moderate), selegiline (7 studies, 810 participants, SMD 0.27, 95% CI 0.13 to 0.41; GRADE: low), huperzine A (2 studies, 70 participants, SMD 1.48, 95% CI 0.95 to 2.02; GRADE: very low) and Ginkgo biloba (7 studies, 2530 participants, SMD 0.36, 95% CI 0.28 to 0.44; GRADE: very low).

Conclusions: Healthcare professionals should ensure that people with dementia are encouraged to exercise and that primary carers are trained and supported to provide safe and effective care for the person with dementia. Acetylcholinesterase inhibitors or memantine should be trialled unless contraindicated.

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Horticultural therapy for dementia patients

C0026838 Purple flowers
Image source: Wellcome Library// CC BY-NC-ND 4.0

Fourteen people attending an adult day programme were recruited to a structured horticultural therapy programme which took place over 10 weeks. The effects were assessed using Dementia Care Mapping and questionnaires completed by family carers.

High levels of wellbeing were observed while the participants were engaged in horticultural therapy, and these were sustained once the programme was completed. This study adds to the growing evidence on the benefits of horticultural therapy for people with dementia who have enjoyed gardening in the past.

Full reference: Hall, J.  et al.  Effect of horticultural therapy on wellbeing among dementia day care programme participants: A mixed-methods study published online before print. Dementia April 11, 2016

The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials.

Groot, C. et al. Ageing Research Reviews. 2016 Jan;25:13-23

Social Care Photography, Department of Health


Non-pharmacological therapies, such as physical activity interventions, are an appealing alternative or add-on to current pharmacological treatment of cognitive symptoms in patients with dementia.

In this meta-analysis, we investigated the effect of physical activity interventions on cognitive function in dementia patients, by synthesizing data from 802 patients included in 18 randomized control trials that applied a physical activity intervention with cognitive function as an outcome measure. Post-intervention standardized mean difference (SMD) scores were computed for each study, and combined into pooled effect sizes using random effects meta-analysis.

The primary analysis yielded a positive overall effect of physical activity interventions on cognitive function (SMD[95% confidence interval]=0.42[0.23;0.62], p<.01).

Secondary analyses revealed that physical activity interventions were equally beneficial in patients with Alzheimer’s disease (AD, SMD=0.38[0.09;0.66], p<.01) and in patients with AD or a non-AD dementia diagnosis (SMD=0.47[0.14;0.80], p<.01). Combined (i.e. aerobic and non-aerobic) exercise interventions (SMD=0.59[0.32;0.86], p<.01) and aerobic-only exercise interventions (SMD=0.41[0.05;0.76], p<.05) had a positive effect on cognition, while this association was absent for non-aerobic exercise interventions (SMD=-0.10[-0.38;0.19], p=.51).

Finally, we found that interventions offered at both high frequency (SMD=0.33[0.03;0.63], p<.05) and at low frequency (SMD=0.64[0.39;0.89], p<.01) had a positive effect on cognitive function.

This meta-analysis suggests that physical activity interventions positively influence cognitive function in patients with dementia. This beneficial effect was independent of the clinical diagnosis and the frequency of the intervention, and was driven by interventions that included aerobic exercise.

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Computer-based cognitive interventions for people living with dementia: a systematic literature review and meta-analysis

García-Casal, J. A. et al. Aging & Mental Health. Published online: 25th Jan 2016

digital 2
Image source: Mattias
Objectives: To estimate the efficacy of computer-based cognitive interventions for improving cognition in people with dementia (PWD).
Method: Online literature databases were searched for relevant studies. Interventions were categorised as follows: cognitive recreation, cognitive rehabilitation, cognitive stimulation or cognitive training. A systematic review, quality assessment and meta-analyses were conducted.
Results: Twelve studies were identified. Their methodological quality was acceptable according to Downs & Black criteria, the weakest methodological area being the external validity. The meta-analyses indicated cognitive interventions lead to beneficial effects on cognition in PWD (SMD −0.69; 95% CI = −1.02 to −0.37; P < 0.0001; I2 = 29%), depression (SMD 0.74; 95% CI = 0.31 to 1.17; P = 0.0008; I2 = 41%) and anxiety (SMD 0.55; 95% CI = 0.07 to 1.04;P < 0.03; I2 = 42%). They benefited significantly more from the computer-based cognitive interventions than from the non-computer-based interventions in cognition (SMD 0.48; 95% CI = 0.09 to 0.87; P = 0.02; I2 = 2%) and depression (SMD 0.96; 95% CI = 0.25 to 1.66; P = 0.008; I2 = 54%).
Conclusion: Computer-based cognitive interventions have moderate effects in cognition, depression and anxiety in PWD. No significant effects were found on activities of daily living. They led to superior results compared to non-computer-based interventions in cognition and depression. Further research is needed on cognitive recreation and cognitive stimulation. There is also a need for longer-term follow-up to examine the potential retention of treatment effects, and for the design of specific outcome measures.
Full text available here