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26 Interventions in Alzheimer’s Disease KCE Reports 111 Table 3. Effects of psychosocial interventions on depressed, aggressive and apathic behaviours of people with dementia Technique Apathy improvement Depression improvement Reality orientation no no no Skills training no no no Reminiscence therapy no no no Validation therapy no no no Behavior training of patients and caregivers (pleasant activities for patients; problem-solving for caregivers) no 1 RCT (also accepted by SBU): limited improvement 50 Snoezelen 2 RCTs (also accepted by Cochrane & SBU): some improvement 50 Other sensory stimulation, gentle care, art therapy Stimulated presence therapy Agression improvement no no no no no no no no no Psychomotor therapy no no 1 RCT (not accepted by Cochrane or SBU): limited improvement 50 Activity therapy no no no NICE-SCIE concludes there is no evidence that standardised approaches, such as validation, cognitive stimulation and reminiscence, reduce behaviour that challenges in people with dementia. In general, this is not the major objective of such approaches, although some improvements in mood have been noted. Little research is yet available regarding music-based approaches, multi-sensory stimulation and bright light therapy. Aromatherapy in severe dementia has been evaluated in two controlled trials with some evidence of benefit in terms of reduced agitation and general neuropsychiatric symptoms. 1 However, these two trials were excluded by SBU because of inclusion criteria. NICE-SCIE also concludes there is limited evidence from one RCT, albeit with relatively small numbers, that a cognitive behavioural therapy (CBT)-based approach may be helpful in treating depressive symptoms in people with AD, and this may also benefit carers who are actively involved in the treatment. 1 Wandering occurs in 15-60% of people with dementia. It represents a diverse range of behaviours which occur for different reasons, thus necessitating a variety of therapeutic approaches. A Cochrane review focussed on non-pharmacological interventions for wandering of people with dementia in the domestic setting. Interventions considered include • exercise and walking therapies, • environmental modification interventions, • behavioural modification interventions, • occupational therapy, • complementary and psycho-social therapies, • Safe Return registration and identification program, • electronic tagging used to restrain a person within a limited area or to locate a person
KCE Reports 111 Interventions in Alzheimer’s Disease 27 In the Cochrane review of 2007 on wandering in the domestic setting, no RCTs were identified. 51 A second systematic review also concluded that there was no robust evidence to recommend the use of non-pharmacological intervention to reduce wandering in dementia. 52 Note that several small, non-randomized studies (mostly in institutional settings) all suggest a decrease in escaping behavior by patients with severe dementia if the exit is obscured 5 (see Table 2, environmental manipulation). Conclusion Behavioral training of patients (or training of caregivers in behavioral management) might reduce challenging behavior in patients (and/or depression in caregivers). However, due to the limited amount of studies, replication of these results is necessary before efficacy can be considered to be proven. No high-quality evidence is available on methods to reduce wandering in dementia. 3.2.2.3 Studies focusing on technological support Many innovative applications of telecommunications have emerged in health care but the evidence is limited. 21 Two studies supported the effects of (computer) technological support, but no evidence could be stated given their differing outcomes (absence of confirmation in a second trial). NICE concluded initial findings support the use of assistive technology (telecare) in aiding people to stay in the community longer, thereby delaying moves to higher dependency care, but further research is needed before any firm conclusions can be drawn. 1 Qualitative evidence on the experience of people with dementia and carers points to the contribution that assistive technology can make by reducing risks and promoting independence. 1 In a comprehensive review of intelligent assistive technology applications 53 , the available tools are grouped as cognitive aids, physiological sensors, environmental sensors, advanced integrated sensor systems, wearable radiofrequency transmitters and the Proactive Activity Toolkit. Most of the tools and research studies focus on the physical disability of younger persons with typically non-progressive brain injury. Unfortunately, no good quality studies have yet been published using such tools in persons with dementia. 53 3.2.3 Interventions that include the caregiver One of the new area’s of dementia research concerns the interventions to prevent the negative consequences of caring for a person with dementia. Care at home for as long as possible is often preferred over institutionalization both by the patient and the familycaregiver. Caring for a person with dementia at home is however intensive and burdensome. Caregivers are at high risk of psychosocial morbidity and associated breakdown in care. Support measures preventing caregivers from becoming overburdened and depressed may theoretically result in a delay of institutionalization. 3.2.3.1 Staff education: effects on patients or caregivers Livingston et al. describe 3 RCTs (as well as 6 other studies), evaluating staff education in managing behavioral problems. It is concluded by the authors that a moderate level of evidence exists to support staff education in improving behavioral problems in dementia. The SBU review also discusses the effect of formal caregiver interventions on caregiver knowledge and attitude. Because only few studies were identified as having sufficient quality, it was concluded that insufficient evidence is available to show that formal caregiver education or training has any effect on their attitude or knowledge. Kuske et al. 54 evaluated nursing home staff training in dementia care (several aspects); they found 3 RCTs of good methodological quality, demonstrating positive effects on the level of caregiver (knowledge and attitude) and care recipient (behavioral disturbances). The authors conclude that the evidence level is low. 54 Two of these 3 studies were also included by Livingston; one study was included by SBU under “communication enhancement” and another study was excluded by SBU.
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KCE reports 33 Effects and costs of
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