Mohammed T. Abou-Saleh

328 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYkey to optimal care. Against this is the argument that even such anultimately devastating disorder as dementia does not obliterate allindividuality and, in consequence, different people with dementiawill have different problems and varied needs, even if there aresome common elements. This does not deny that things like DCMand RO might have a general role, but it does mean there is also aneed to consider individuals and their particular problems andcircumstances.A wide range of psychological interventions directed at specificproblems, such as incontinence, memory failures and socialbehaviour, have now been described. These are based more inthe kinds of psychological treatments developed for use with otherclinical populations. Space does not permit an extensive descriptionof these and more detailed information can be gained fromother sources 1,2,13 . This section will merely offer a few illustrativeexamples.Incontinence has always proved a difficult and almostintractable problem for psychological intervention. Nevertheless,some evidence of techniques able to produce beneficial effects hasappeared. A system of checking for wetness and prompting goingto the toilet has been found to produce positive effects, increasingthe number of ‘‘dry checks’’ 14 . It is also interesting that one studyhas suggested that earlier failures to produce benefits with similarprogrammes might be at least partially attributable to staff failingto comply with the regime, rather than a failure of the method toprovide positive effects when properly applied 15 .Aimless wandering can also be another feature that is difficultto manage. The adaptation of principles based on operantconditioning has shown some promise as a means to reduce thisbehaviour 16,17 . An interesting point in relation to this particularproblem and, by implication, other problems as well, is that it isoften unfortunately seen as secondary to intellectual loss andtherefore only remediable if the primary problem can be tackled 13 .Finally, one possible way of ameliorating the problem ofmemory loss is to use external memory aids as prompts in order tolessen the load on the individual’s own memory and to supportretrieval. An encouraging account has described the use of thisstrategy with some success in the execution of daily living tasks,such as preparing a drink or snack 18 .COMMENTThe most important conclusion that can be reached aftersurveying the evidence on psychological and psychosocial interventionsfor those with dementia is that people with even quitemarked levels of dementia are responsive to psychological andenvironmental manipulation. This offers the essential foundationfor the development of therapeutic or management strategiesbased on psychological principles.Quite simple manoeuvres, such as rearranging chairs in groupsto facilitate conversation, rather than leaving them in longregimented lines, can improve social interaction. Other relativelysimple interventions can contribute to maintaining the basic skillsassociated with independent living. Despite being positivelyregarded by staff and patients, general methods like RO andreminiscence are of limited value and DCM remains to beevaluated. The best support is for RO, and indicates that smallpositive changes in orientation can be achieved. Since thesemethods are easy to apply, they can also be used as a generalbackground on which more specific interventions can be built, andthe successful addition of behavioural training to RO exploited inone investigation 22 can be seen as an example of this.It may be that an important spin-off from general methods likeRO is their popularity with direct care staff. Whilst this remains tobe formally demonstrated, their use may help create and maintaina more optimistic and therapeutic attitude in staff, which can be avery worthwhile achievement in itself. In turn, this should make iteasier to implement more specific interventions, more focused onindividual needs.As with psychological interventions in other contexts, the bestresults are likely to follow from the careful functional analysis ofproblem behaviour, whether this be a lack of behaviour orexcessive and inappropriate behaviour, with specific interventionschosen in relation to the exact nature of the problem.Overall, psychological and psychosocial interventions in thetreatment and management of those with dementia are nowcapable of achieving modest but useful beneficial effects. Theynow must be regarded as a worthwhile part of any overallmanagement strategy.COMMUNITY-BASED INTERVENTIONSMost of the elderly population with dementia live in thecommunity and are looked after by relatives, who can be underconsiderable strain 1 . Supporting carers therefore assumes considerableimportance and extensions of the approaches describedabove have been made to deal with problems encountered in thoseresident in the community 13 (a wider discussion of communitycare issues is provided in Sections MI and MII).One of the most obvious strategies is to provide support groupsfor carers, which may concentrate on providing informationabout dementia and discuss coping strategies, especially thoseused by group members. This strategy is described in greater detailelsewhere 1 .More formal methods, such as RO, have been adapted for usewith community residents attending day hospitals. Similar effectsto those obtained in applying RO in psychogeriatric wards andnursing homes were obtained. Again, the impact was mostpronounced for orientation measures but with some effect onmood as well 19 .Finally, it is possible to use informal caregivers, such as spousesand children, as agents to implement more specific psychologicalinterventions of the kind outlined in the immediately precedingsection 20,21 . Problems tackled with some indication of successinclude the improvement of self-care skills and social interaction.REFERENCES1. Miller E, Morris R. The Psychology of Dementia. Chichester: Wiley,1993.2. Woods RT. Psychological ‘‘therapies’’ in dementia. In Woods RD,ed., Handbook of the Clinical Psychology of Ageing. Chichester: Wiley,1996.3. Folsom JC. Reality orientation for elderly mental patients. J GeriatPsychiat 1968; 1: 291–307.4. Holden UP, Woods RT. Reality Orientation: PsychologicalApproaches to the ‘‘Confused’’ Elderly. Edinburgh: ChurchillLivingstone, 1988.5. Holden UP, Woods RT. Positive Approaches to Dementia Care.Edinburgh: Churchill Livingstone, 1995.6. Goldwasser AN, Auerbach SM, Harkins SW. Cognitive, affective andbehavioural effects of reminiscence group therapy on dementedelderly. Int J Aging Hum Dev 1987; 25: 209–22.7. Gibson S. What can reminiscence contribute to people with dementia?In Bornat J, ed., Reminiscence Reviewed: Evaluations, Achievements,Perspectives. Buckingham: Open University Press, 1994; 46–60.8. Kitwood T, Bedin K. Towards a theory of dementia care: personhoodand well being. Ageing Soc 1992; 12: 269–87.9. Kitwood T. Dementia Reconsidered: The Person Comes First.Buckingham: Open University Press, 1997.10. Fox L. Mapping the advance of the new culture in dementia care. InKitwood T, Benson S, eds, The New Culture of Dementia Care.Buckingham: Open University Press, 1995; 70–4.