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20 Interventions in Alzheimer’s Disease KCE Reports 111 3.2.2 Interventions addressing the patient 3.2.2.1 Studies focussing on specific interventions In the following table we have mentioned the level of evidence supporting the various interventions targeting the person with dementia, describing studies focussing on the intervention itself. Included are interventions addressing patient cognition, patient emotion, patient sensory enhancement; physical activity interventions; functional performance interventions; communication/interaction/relationship interventions; environmental interventions. Table 2. Non-pharmaceutical interventions targeting the person with dementia (specific interventions) Intervention Method and aims Number of studies (mainly RCTs; if other type accepted in the review listed it is mentioned below) and level of evidence or effect size as given in the reference Patient cognition Reality Orientation (RO) Cognitive stimulation or training Reminiscence therapy Multimodal intervention, contains formal RO in small groups; 24-hour RO at each contact; attitude RO for all interacting partners. Unimodal specific exercises directly aimed at memory improvement in mild AD, avoiding frustration. Two types of strategies: restorative (trying to improve functioning in specific domains to premorbid levels) and compensatory strategies (‘working around’ cognitive deficits). Cognitive training: guided practice on memory, attention, problem-solving (executive functions). Cognitive stimulation: repetition of orientation information (e.g. month, famous faces) Cognitive rehabilitation: individualised approach, identification of goals and strategies to improve functioning in everyday context, this can include various forms of cognitive therapy. Note: definitions not used consistently in all publications Contemplation of experiences from a life (old newspapers and Patient emotion Livingston: 2 Studies, low level of evidence 5 Frank: 14 Studies (also including cognitive stimulation, reminiscence therapy, validation therapy): low level of evidence as 8 Studies were negative 29 1 Cochrane review (2000) but no studies accepted by SBU, mostly because of doubt on the diagnosis dementia: no evidence DIMDI: 2 partly positive studies 28 NICE-SCIE: 3 studies, no effect on behaviour. 1 Livingston: 4 RCTs (2 also included by Cochrane), studying cognitive training or stimulation: moderate level of evidence (evidence not consistent), effect lasting months 5 Sitzer: 14 RCTs (including 8 of the 9 Cochrane review studies; 2 other RCTs only 5 participants), and 5 non-RCTs. All 19 studies: medium effect size for learning and memory, restorative strategies may result in larger effect size. Five studies with highest quality: overall effect size below 0.2 (very low) 30 1 Cochrane review (2003), including 9 studies on cognitive training only (of which 5 studies excluded by SBU); concluding that no significant positive nor negative effects were found; no evidence is available. No studies found on cognitive rehabilitation. SBU: 1 study on cognitive stimulation (also included in Livingston): significant improvement in cognition was seen, but only in a single study; hence no evidence 21 NICE: 4 studies on cognitive stimulation on a background of ChEI therapy: 3 positive trials (including an RCT with n=13), 1 negative trial. 1 Livingston: 2 very small RCTs (5 resp. 9 subjects) with positive effect, low level of evidence 5
KCE Reports 111 Interventions in Alzheimer’s Disease 21 Validation therapy Self- maintenance therapy Individualized special instruction “Snoezelen”, multisensory stimulation Other sensory stimulation a household items) and sharing these with others (group may include relatives). Aims to promote social interaction and self-esteem. Offers security to the patients using verbal and non-verbal communication, leaving them in their own emotional state. Aims to reduce anxiety. Based on Rogerian humanistic psychology. Multimodal training of selfrelated knowledge and activities of daily living, and ensuring that communication is validating. Sessions with focused individual attention and participation in an appropriate activity. Individualized program including changing distressing situations, lighting, sensory stimulation, aromatherapy, and education of care providers on how to best assist residents in activities of daily living White noise: low intensity, monotonous sound (eg whirling fan) as an auditory stimulation intervention. Slow stroke massage, hand massage and therapeutic touch, aromatherapy, smell, or taste. TENS (transcutaneous electrical nerve stimulation). Acupuncture for vascular dementia. Patient sensory enhancement 1 Cochrane review including 4 small RCTs (of which only 1 accepted by SBU) with significant effect on cognition, mood and behavior low level of evidence 31 . SBU:1 RCT without positive effect: no scientific evidence 21 DIMDI: two negative studies 28 NICE-SCIE: 4 studies, no effect on behaviour. 1 Livingston: 1 study, evidence level: low. 5 1 Cochrane review (2003): no evidence, theory has been called into question 21 DIMDI: 3 studies, no difference vs usual care in two studies 28 NICE-SCIE: 4 studies, no effect on behaviour. 1 Livingston: 0 studies, hence no evidence 5 Livingston: 1 study, low level of evidence 5 Livingston: 3 RCTs (one with N=5; 2 others by the same author and included by Cochrane but both replaced by a larger update study from the same author), moderate level of evidence, but no lasting effect 5 1 Cochrane review (2002), 2 studies (both interventions differed): no evidence, one study showed effects for some outcomes; result confirmed by SBU 21 DIMDI: 4 studies on snoezelen (3 by the same author); same results as Cochrane and SBU review 28 NICE-SCIE: 2 studies on multisensory stimulation vs active control, no effect on behaviour. 1 Livingston: 1 RCT (8 subjects) on white noise: no effect (no evidence) Livingston: 3 RCTs on massage or combined forms of sensory stimulations, showed diverging results on behavior 5 Cochrane review: 1 Study of massage to improve behavior and 1 study of touch to improve eating : both positive effect but evidence insufficient 32 1 Cochrane review (2003) for aromatherapy but no studies accepted by SBU for aromatherapy or massage: no evidence 21 . One systematic review on aromatherapy 33 , reporting conflicting results, hence no evidence 1 Cochrane review: meta-analysis of 3 trials on TENS, applied to the patient’s back to improve cognition and behavior in early and mid-stage AD a One review on art therapy, and one review on animal therapy (including Pets to improve behavior) were retrieved but discarded because of methodological problems.
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KCE reports 33 Effects and costs of
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