The effects of psychosocial methods on depressed, aggressive and apathetic behaviors of people with dementia: a systematic review

OBJECTIVES: This systematic review seeks to establish the extent of scientific evidence for the effectiveness of 13 psychosocial methods for reducing depressed, aggressive or apathetic behaviors in people with dementia. METHODS: The guidelines of the Cochrane Collaboration were followed. Using a predefined protocol, ten electronic databases were searched, studies selected, relevant data extracted and the methodological quality of the studies assessed. With a Best Evidence Synthesis the results of the included studies were synthesized and conclusions about the level of evidence for the effectiveness of each psychosocial method were drawn. RESULTS: There is some evidence that Multi Sensory Stimulation/Snoezelen in a Multi Sensory Room reduces apathy in people in the latter phases of dementia. Furthermore, 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. For the other ten psychosocial methods there are no or insufficient indications that they reduce depressive, aggressive or apathetic behaviors in people with dementia. CONCLUSIONS: 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.     

Guidelines for psychosocial interventions in dementia care: a European survey and comparison

Objective

The effectiveness of psychosocial interventions in treating people with dementia and their carers is increasingly emphasised in the literature. Dementia guidelines should summarise the scientific evidence and best practice that is currently available, therefore, it should include recommendations for psychosocial interventions. The aims of our study were (1) to collate dementia guidelines from countries across Europe and to check whether they included sections about psychosocial interventions, and (2) to compare the methodological quality and the recommendations for specific psychosocial interventions in these guidelines.

Methods

The European dementia guidelines were inventoried. The methodological quality of the guideline sections for psychosocial interventions was assessed with the (AGREE) Appraisal of Guidelines Research and Evaluation instrument. The recommendations for specific psychosocial interventions were extracted from each of these guidelines and compared.

Results

Guidelines for psychosocial interventions were found in five of 12 countries. Guideline developers, methodological quality and appreciation of available evidence influenced the inclusion of psychosocial interventions in dementia guidelines from Germany, Italy, the Netherlands, Spain and the UK. The UK NICE SCIE guideline had the best methodological quality and included the most recommendations for psychosocial interventions. Physical activity and carer interventions were recommended the most across all guidelines.

Conclusion

The inclusion of psychosocial interventions in dementia guidelines is limited across Europe. High‐quality guidelines that include psychosocial interventions and are kept up to date with the emerging evidence are needed. Throughout Europe, special attention to the implementation of evidence‐based psychosocial care is needed in the next few years. Copyright © 2011 John Wiley & Sons, Ltd.     

Meta-analysis of psychosocial interventions for people with dementia and anxiety or depression

Abstract

Objectives: Assess the effectiveness of psychosocial interventions for depression and anxiety in people with dementia (PWD) or mild cognitive impairment (MCI).

Method: OvidMedline, PsychInfo and Embase were searched for studies on the 5^th August 2017. The efficacy of the studies was estimated using meta-analyses.

Results: Eight RCTs were included. No RCTs were identified for people with MCI. Four RCTs found that psychosocial interventions (multicomponent intervention, Tai Chi, problem adaptation therapy and exercise/walking) were effective at reducing symptoms of depression in PWD who were depressed. One study (Tai Chi) found that these reductions were no longer evident at six-month follow-up. Another study, not included in the meta-analyses, found that pleasant events behaviour therapy and problem solving behaviour therapy improved depression symptoms and this effect remained significant at follow-up. Three RCTs found that psychosocial interventions (music therapy and cognitive behavioural therapy (CBT)) reduced symptoms of anxiety in PWD who were anxious. Evidence from two of these RCTs (music therapy and CBT) showed that these improvements were evident at three to six-month follow-up.

Conclusion: The identified psychosocial interventions are effective at reducing symptoms of depression or anxiety in PWD experiencing these symptoms. This review is limited by the quality of studies, small sample sizes and the heterogeneity of the interventions, therefore high quality studies with larger sample sizes are required to test the efficacy of specific interventions such as CBT.     

Perceptions of a psychoeducation program for caregivers of persons with dementia at end of life: a qualitative study

Objectives: Caregivers (CG) of persons with dementia have described positive and challenging experiences related to caring for a person with a neurological disease. This study explored perceived benefits and challenges of a unique psychoeducation program provided at end of life (EOL) jointly attended by current and bereaved CGs of persons with dementia, residing in a hospital Specialized Care Unit.

Method: Semi-structured interviews were held with sixteen participants and analyzed with content analysis.

Results: Program benefits were perceived by CGs such as: (i) enhanced emotional well-being, (ii) increased feelings of preparedness for EOL, and (iii) personal growth into role models. Within the organization the program was perceived as promoting relationship-centered care and increasing resources. Challenges such as diverse CG preferences, day-time scheduling and limited involvement of unit staff were perceived as barriers.

Conclusions: This program fills a gap in care for CGs at the critical stage of EOL with continuity into bereavement. Implications for practice include: increasing engagement of unit staff for involvement and tailoring of the program, and translation of the program into alternative settings like long-term care. Policies outlining the support needs and resources for CGs through EOL within and outside the hospital are necessary to ensure access and continuity of care.     

Qualitative participatory evaluation of a psychosocial rehabilitation program for individuals with severe mental illness

Clubhouse International is a nonprofit organization that supports the creation of community-based clubhouses around the world. Using a psychosocial rehabilitation approach, clubhouses provide individuals living with mental illness opportunities to successfully live and work in their communities through a variety of programs including employment opportunities, housing support, case management, and social programs. Progress Place, an accredited clubhouse located in Toronto, Ontario, Canada, partnered with evaluators to better understand their psychosocial rehabilitation approach for individuals with severe mental illness. The purpose of the present study was to undertake a participatory evaluation in order to identify mechanisms of change and recovery outcomes that occur for clubhouse members at Progress Place. In the first phase, six focus groups with staff, members, and board members, were conducted. In the second phase, 11 semistructured group interviews were used to confirm and provide feedback on the mechanisms and outcomes that were found. Analysis of responses revealed specific mechanisms (e.g., elevated sense of respect, autonomy, and purpose) and recovery outcomes (e.g., personhood, feeling at peace, acquiring skills) that occur for clubhouse members. Participants reported that themes accurately represented their experience and felt understood by the evaluators. The present study fills a gap in the psychosocial rehabilitation literature by identifying mechanisms of change that lead to recovery outcomes for members who utilize these programs. This study also provides clear direction for future research examining the breadth of outcomes and change mechanisms.     

Psychosocial interventions for people with dementia: a synthesis of systematic reviews

Objectives: Over the last 10 years there has been a multitude of studies of psychosocial interventions for people with dementia. However, clinical services face a dilemma about which intervention should be introduced into clinical practice because of the inconsistency in some of the findings between different studies and the differences in the study qualities and trustworthiness of evidence. There was a need to provide a comprehensive summary of the best evidence to illustrate what works.

Methods: A review of the systematic reviews of psychosocial interventions in dementia published between January 2010 and February 2016 was conducted.

Results: Twenty-two reviews (8 physical, 7 cognitive, 1 physical/cognitive and 6 other psychosocial interventions) with a total of 197 unique studies met the inclusion criteria. Both medium to longer-term multi-component exercise of moderate to high intensity, and, group cognitive stimulation consistently show benefits. There is not sufficient evidence to determine whether psychological or social interventions might improve either mood or behaviour due to the heterogeneity of the studies and interventions included in the reviews.

Conclusion: There is good evidence that multi-component exercise with sufficient intensity improves global physical and cognitive functions and activities of daily living skills. There is also good evidence that group-based cognitive stimulation improves cognitive functions, social interaction and quality of life. This synthesis also highlights the potential importance of group activities to improve social integration for people with dementia. Future research should investigate longer-term specific outcomes, consider the severity and types of dementia, and investigate mechanisms of change.     

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

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 0.47; 95% CI = 0.16 to 0.78; p = 0.003; I² = 0%) 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%).

Conclusion: Computer-based cognitive interventions have moderate effects in cognition, and anxiety and small effects in depression 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. 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.     

Effects of combined intervention programmes for people with dementia living at home and their caregivers: a systematic review

OBJECTIVE: This study reviews the evidence for effects of combined intervention programmes for both the informal caregiver and the person with dementia. METHOD: Systematic review. Electronic databases and key articles were searched for effect studies of combined programmes, published between January 1992 and February 2005. The resulting 52 reports were scored according to set inclusion criteria. RESULTS: Twenty five reports relating to 22 programmes met the inclusion criteria. Various aspects of caregivers' mental health and burden were studied. Best results were obtained regarding general mental health. Other aspects often showed modest and varying results. Caregivers' competence was less often addressed. The effects on the cognitive and physical functioning, behavioural problems and survival of the persons with dementia were modest and inconsistent, whereas their mental health is positively affected and admittance to long stay care is often delayed. CONCLUSION: Combined programmes may improve some, not all, aspects of functioning for caregiver and person with dementia. Care professionals must define their programme goals and target groups before advising their clients on a combined programme. Research may focus on the effects of programmes that were introduced fairly recently and on subgroups of caregivers (female caregivers, depressed caregivers and people with dementia, and minorities).     

Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review

BACKGROUND: Wandering occurs in 15-60% of people with dementia. Psychosocial interventions rather than pharmacological methods are recommended, but evidence for their effectiveness is limited and there are ethical concerns associated with some non-pharmacological approaches, such as electronic tracking devices. OBJECTIVE: To determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia. DESIGN: A systematic review to evaluate effectiveness of the interventions and to assess acceptability and ethical issues associated with their use. The search and review strategy, data extraction and analysis followed recommended guidance. Papers of relevance to effectiveness, acceptability and ethical issues were sought. RESULTS: (i) Clinical effectiveness. Eleven studies, including eight randomised controlled trials, of a variety of interventions, met the inclusion criteria. There was no robust evidence to recommend any intervention, although there was some weak evidence for exercise. No relevant studies to determine cost effectiveness met the inclusion criteria. (ii) Acceptability/ethical issues. None of the acceptability papers reported directly the views of people with dementia. Exercise and music therapy were the most acceptable interventions and raised no ethical concerns. Tracking and tagging devices were acceptable to carers but generated considerable ethical debate. Physical restraints were considered unacceptable. CONCLUSIONS: In order to reduce unsafe wandering high quality research is needed to determine the effectiveness of non-pharmacological interventions that are practically and ethically acceptable to users. It is important to establish the views of people with dementia on the acceptability of such interventions prior to evaluating their effectiveness through complex randomised controlled trials.     

Remaining hopeful in early-stage dementia: A qualitative study

Objectives: Improving the quality of life for people living with dementia is widely accepted as an important outcome in dementia care services. Positive psychology, the systematic study of strengths, capacities, and personal resources, is one framework for understanding how a person with dementia might achieve this. This study investigated the subjective experience of hope–a construct from the discipline of positive psychology in older people with early-stage dementia.

Method: Ten volunteer participants over the age of 65 years were recruited from a memory clinic in England. Semi-structured interviews were used to explore participants’ hopes, in terms of their personal meaning, their resources, and the potential barriers and facilitators of hope in dementia. Interviews were analyzed using interpretative phenomenological analysis (IPA).

Results: Eight themes were extracted, subsumed under two higher-order themes: ‘live in hope or die in despair’ and ‘keep living and keep living well’. Participants described how their internalized hope-fostering beliefs that were often learned during childhood were challenged by the reality of hope-hindering experiences associated with old age and dementia. A balancing process of re-appraisal enhanced resolution and this sense of stability then allowed them to develop positive attitudes towards common age-related constraints in their health and social circumstances.

Conclusion: The findings offer insight into the existence, nature, and relevance of hope in the lives of people with early-stage dementia. They provide a useful framework for developing hope-fostering strategies in early interventions that aim to assist individuals with dementia to maintain their quality of life.