Advances in psychiatric treatment (2014), vol. 20, 340–349  doi: 10.1192/apt.bp.113.

011957

ARTICLE Psychosocial interventions for

dementia: from evidence to practice
Bhamini Patel, Mark Perera, Jill Pendleton, Anna Richman & Biswadeep Majumdar

Bhamini Patel is a CT3 trainee of dementia and it is the caregiver’s responsibil-

in old age psychiatry, Mersey Care SUMMARY
ity to ensure that it is maintained. Person-centred
NHS Trust. Mark Perera is an This article presents evidence for the efficacy
ST6 trainee in old age psychiatry, practice recognises the underlying needs of the
of psychosocial interventions for people with
5 Boroughs Partnership NHS individual, often expressed through behaviour.
Foundation Trust. Jill Pendleton
dementia and their carers. The evidence base
The paradigm shift from ‘managing’ behavioural
is an advanced practitioner in is not yet robust enough to clearly suggest
which interventions are most suited for which and psychological symptoms of dementia (BPSD)
dementia, Mersey Care NHS Trust.
Anna Richman is a consultant old environment. However, from our literature review towards improving well-being, engagement and
age psychiatrist, Mersey Care NHS there appears to be reason to use music therapy, quality of life represents a significant change.
Trust. Biswadeep Majumdar is aromatherapy, life story work, animal-assisted These goals are more hopeful, leaving therapeu-
a consultant old age psychiatrist,
therapy and post-diagnosis/carer support work. tic nihilism in the past. Reducing antipsychotic
Mersey Care NHS Trust.
Correspondence  Dr Bhamini We focus on both the traditional outcome measures prescribing (Banerjee 2009) presents another op-
Patel, Waterloo Day Hospital, Park of behavioural and psychological symptoms portunity to exploit these approaches. A review of
Road, Liverpool L22 3XR, UK. Email: of dementia (BPSD) and the more difficult to 26 non-pharmacological intervention categories
[email protected] measure, but equally important, person-centred concluded that non-pharmacological therapies
outcomes of non-pharmacological interventions,
are useful, versatile and potentially cost-effec-
as their properties are distinctly different from
tive in improving outcomes and quality of life
those of pharmacological agents.
(Olazarán 2010); however, they necessitate staff
LEARNING OBJECTIVES time, raising issues regarding priorities and risk
• Be aware of the range of psychosocial inter­ (Lawrence 2012).
ventions. The essential component is the belief that distress
• Have a better understanding of the possible and behaviour are expressions of unmet need – all
outcomes from given interventions. behaviour having meaning – and are a response to
• Be aware of the paradigm shift from managing the challenges dementia presents (Kitwood 1997).
BPSD to a person-centred approach that focuses The key appears to be formulation or behavioural
on the patient’s well-being and quality of life. analysis (Moniz-Cook 2012) to understand the
DECLARATION OF INTEREST behaviour and its function for each person.
None. •• Non-pharmacological approaches should be the
first line of intervention (Douglas 2004; National
Collaborating Centre for Mental Health 2007).
This article is an update to the overview in
Advances by Douglas et al (2004). We summarise
the most well-researched psychosocial approaches BOX 1 Psychosocial approaches for
for dementia by focusing on those with good- dementia that are in use but research
quality evidence, and acknowledge some of the is ongoing
newer and less-researched interventions listed in
• Cognitive retraining and cognitive rehabilitation
Box 1.
The recurrent theme throughout the literature • Assistive technology (e.g. telecare, digital scrapbook,
regarding the efficacy of non-pharmacological immersive space, intelligent lighting)
interventions for dementia is the need for more • Dementia training for carers
robust evidence. Reasons for this include that • Sonas (a multisensory stimulation technique)
research funding is largely targeted at biomedical • Play therapy
approaches and that study designs are not always • Drama therapy/storytelling
a good fit for the outcomes measured.
• Meal positioning
Kitwood (1997) proposed that a person-centred
approach should be the bedrock for supporting
• Therapeutic use of touch
people with dementia. The essential tenet is that • Occupational-based therapies
personhood remains throughout the experience

340
 Psychosocial interventions for dementia

•• Non-pharmacological approaches provide oppor- in the principles of reminiscence, maintaining

tunities to maintain personhood that traditional communication and a sense of self, life story work
models lack in terms of meeting complex need. has demonstrated significant growth over the
•• Classification of BPSD is complex, for example past 10 years. McKeown et al ’s (2006) systematic
cognitive to sensorimotor activities, product to review demonstrated a range of methodological
process (Perrin 2000) or the stepped care model approaches utilised to explore life story work,
(Brechin 2013). although studies largely focused on staff
•• Interventions should be repositioned from perceptions, with patient and carer experience
managing BPSD to improving well-being. less well explored. The reviewers concluded that
life story work has ‘far-reaching’ benefits in health
Here, we have grouped the reviewed psychosocial
and social care, but that high-quality research
interventions under the categories of creative,
is scarce.
sensory, activity-based, psychological, carer-
Findings support life story work as enabling
focused and environmental.
the person to make sense of their identity and to
connect the past with the present (Oyebode 2008:
Creative interventions pp. 151–167). Moos & Bjorn (2006) report that life
These have developed significantly over the past story work has a role in increasing self-esteem and
10 years as a means of engagement and expression quality of life, although they found diverse aims
for people with dementia. Described by Killick & and methodologies.
Allan (1999) as the ‘undiminished possibility’, they This intervention is recognised as valuable,
encourage participants and staff to see creativity but it is complex and requires staff training
as an opportunity for engagement not provided (Beard 2012).
by other non-pharmacological approaches. Often
outcomes are not classified in terms of BPSD as Movement/dance therapy
this term jars with the person-centred philosophy. Beard (2012) reported that movement and dance
The focus is on promoting well-being, quality studies demonstrated small changes in behavioural
of life and enrichment of experience, thereby symptoms (e.g. reducing agitation), although the
improving mood and behaviour. Studies of creative main focus was on increasing engagement with
arts-based approaches for dementia are mostly others. Dance and movement therapy provides
inadequate in terms of systematic study design, opportunities for non-verbal communication,
measurement tools and methods of analysis, and supporting speech and expression of thoughts,
there is disagreement in terms of methodologies memories and emotions, and creative self-
and evaluation (Beard 2012). However, a few expression (Dulicai 2005).
adequately controlled evidence-based studies show
favourable results for reducing BSPD. Music therapy
Music therapy has been used for a variety of
Art therapy conditions and patient groups (e.g. people with
Art therapy with people with dementia is distinct intellectual disability) and it is only in the past few
from art as therapy, as its basis is leisure (Killick
1999). The application of art therapy is varied.
BOX 2 Case study 1: Life story work
Drawing, painting and using arts media has
therapeutic potential in itself without using it Mr K was a retired office manager, with a and angry. Eventually, his wife felt unable
as a clinical therapy to stage dementia. Studies wife and two children, who had enjoyed a to cope and the situation at home became
by Kahn-Denis (1997) and Rentz (2002) focus successful career and been a keen golfer. untenable. He was admitted to the ward,
more on positive outcomes: across these studies He was diagnosed with semantic dementia a smart intelligent man unable to express
80 participants expressed pleasure and showed which soon led to complex problems at his thoughts and feelings and unable to
sustained attention and self-esteem. Ziesel’s home. He had had input from speech and grasp what was being said. He was clearly
Arts for Alzheimer’s programme (Zeisel 2009) language therapists and occupational distressed and angry, so his wife brought his
demonstrated the potential that people living with therapists to support him and his wife life story book to the ward. This had a huge
at home, which included developing a effect on the ward staff in helping them
dementia have to enjoy art appreciation.
life story book. This detailed Mr K’s life, understand Mr K and his behaviour. When
his achievements, his special moments people have few words, communication can
Life story work and his family and friends. He became be difficult and the life story book became a
Life story work involves reviewing and evaluating extremely frustrated with his deficits in tool for engagement that gave Mr K a sense
a person’s life events by working with them and comprehension and expressive language of pride and visibly reduced his anxiety and
their families, recording information and using it and increasingly frequently he became upset stress.
to help with care (Thompson 2011) (Box 2). Rooted

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Patel et al

years that there have been more rigorous studies improved night-time sleep, increased daytime
of its use with people with dementia. It is usually wakefulness and reduced agitated behaviour in
delivered in groups by a trained music therapist, the evening.
and it makes use of the expressive elements of Figueiro (2008) proposes a 24-hour lighting
music (such as rhythm, melody and tone) to relate scheme that can positively affect sleep, mood and
between the therapist and patients. Previous agitation as well as reduce the risk of falls.
musical skills are not required to be able to engage
in this therapy. Ueda et al (2013) reviewed the Aromatherapy
literature on the topic and concluded that music Aromatherapy is a complementary therapy that
therapy had moderate effects on anxiety and involves the use of essential oils (mainly Melissa
smaller effects on behavioural symptoms; thus, balm and lavender) applied directly to the skin,
they felt that there is evidence that this therapy is heated in a burner or placed in a bath. It is thought
effective for BPSD. to work mainly by providing sensory stimulation
and the variety of application methods means it
Sensory interventions can be used in different settings. Fung et al (2012)
Light therapy concluded that their review of 11 randomised
Light therapy has shown mixed but promising controlled studies showed evidence in favour
results. The physiology of our internal biological of the use of aromatherapy for BPSD as well as
clock responsible for our sleep/wake cycle improvement in cognition and quality of life, but
is complex. This internal biological clock is also noted reports of adverse effects.
situated in the suprachiasmatic nuclei of the
hypothalamus. Although it is sensitive to social Multisensory approaches
activities and meal times for its regulation, its Rooms specifically designed to achieve ‘sensori­
strongest regulator is the light/dark cycle (Hanford stasis’ are thought to reduce agitated behaviours.
2013). It is known that with the progression of Sensoristasis, which has been in use since the
neurodegenerative dementias, sleep is disrupted; 1970s, is a balance between being over- and
therefore maintaining the sleep/wake cycle is a under-stimulated (Sanchez 2013). A specialised
biologically plausible intervention. The variation multisensory room may contain items such as
in the intensity of light used across studies as coloured lights, water columns and aromatherapy.
well as the timing were critical to the outcomes Sanchez et al (2013) carried out a review
observed (Dowling 2005), and likely account for to determine the efficacy of this approach in
the differences in study results. dementia. They reviewed papers from 1990 to
A Cochrane review of eight trials (Forbes 2009) 2012 and although 63 studies were found, only
revealed that there was inadequate evidence of 18 fulfilled their inclusion criteria. They looked at
the effectiveness of light therapy in managing the outcomes of behaviour, mood, cognitive level
cognition, sleep, function, behaviour or psychiatric and communication/interaction. With respect
disturbances associated with dementia, and that to behaviour there are conflicting results; some
further studies of high methodological quality and studies show a decrease in agitation, some find no
further research are required. It is important to significant difference. Interestingly, one study in
note that the review authors defined light therapy which multisensory approaches were integrated
as ‘any intensity and duration’. In fact, a study into daily care showed that improvements in
by Barrick et al (2010) showed that agitation certain aspects of behaviour, such as apathy and
was actually higher under high-intensity bright aggression, were maintained 15 months after the
morning light. new regime had been introduced. Integration of the
Burns et al (2007) showed that after 2 weeks of approach into the daily care routine also showed a
light therapy at 10 000 lux from 10.00 h to 12.00 h significant improvement in mood. It seems that the
there were improvements in the Cohen-Mansfield use of multisensory approaches in early dementia
Agitation Inventory (CMAI; Cohen-Mansfield improves scores on the Mini-Mental State
1986), and it is suggested that individuals with Examination (MMSE; Folstein 1975), although
higher initial CMAI scores may benefit the most the outcome of cognition has not been studied
from light therapy. More recently, Hanford & extensively. On the outcome of verbal and non-
Figuero (2013) published a review of 17 studies verbal communication it seems that the integrated
on the effects of light therapy on sleep, agitation approach produced significant improvements. The
and mood. Regarding sleep, the authors found that long-term effectiveness of these approaches needs
exposure to bright light at >1000 lux at the cornea to be studied in further trials.

342 Advances in psychiatric treatment (2014), vol. 20, 340–349  doi: 10.1192/apt.bp.113.011957
 Psychosocial interventions for dementia

Animal-assisted therapy activities. The appropriate use of activity becomes

the essential component, matching activity with
Animal-assisted therapy covers any form of
the abilities of the person to engage in something
therapy that involves animals. For people with
which gives them meaning. Brooker and colleagues
dementia it usually means hands-on interaction
(2007) developed an activity-based project to
with a domesticated pet brought into the care
look at enrichment opportunities founded on the
setting by a trained handler. It is thought to work
assumption that people with dementia are able and
partly through sensory stimulation, but can also
entitled to enjoy life. They acknowledge that the
help trigger positive memories and improve social
evidence was weak but the observable signs were
interaction. Bernabei et al ’s 2013 review noted that
undeniable (Beard 2012) in terms of a sense of
there were improvements on levels of agitation and
connection, well-being, belonging, self-autonomy
quality of social interaction, but studies looking at
and identity.
the effects on cognition and mood were lacking.

Psychological interventions
Activity-based interventions
Doll therapy
Exercise
James et al (2006) and Verity (2006) have provided
Physical exercise features prominently in terms
demonstrable efficacy for the use of dolls as
of primary prevention of dementia in reducing
therapy for people with dementia. Although not
vascular risk. Exercise appears to have a neuro­
well understood in terms of theoretical base, it
protective function, increasing hippocampal
has grown from the work of Bowlby and attach­
volume, although the direct effect on cognition is
ment theory (Bowlby 1960) and links the way
still unclear; there are obvious benefits for quality
people with dementia experience the world (as
of life, physical health and affective symptoms.
unfamiliar and unsafe) to heightening their need
Forbes et al (2008) state that there is more
for attachment (frequently attaching themselves to
conclusive evidence regarding aerobic exercise,
staff members, other residents or objects) (Box 3).
with National Institute for Health and Care
Meissen’s (1993) work has also been integrated to
Excellence (NICE) guidance (National Institute
produce a rationale for the use of dolls as therapy.
for Health and Clinical Excellence 2008)
It was the Newcastle Challenging Behaviour
recommending 30 min of aerobic exercise five
Service that delivered the first empirical studies of
times a week. Extrapolation from studies with
healthy older people and animals is difficult
owing to methodological issues, but the potential BOX 3 Case study 2: doll therapy
of physical exercise to ameliorate the symptoms of
dementia is interesting. Mr A was a resident in a nursing home, having a doll, yet he chose it himself and
Buchman and colleagues (2012) concluded with dementia and complex needs as was reassured by the connection he formed.
that higher levels of daily activity are associated well as loss of communication skills. As
In this case the unsettled and agitated
with a reduced rate of Alzheimer’s disease, and a result he was becoming very distressed
behaviour can be an expression of unmet
Winchester et al (2012) found that for a group of and for long periods would pace up and
psychological need. Kitwood (1997) states
down the corridors, getting involved in
people with early Alzheimer’s disease, walking for that these unmet needs are often the need
angry exchanges with other people. One
over 2 h a week for 1 year led to a significant increase for attachment, comfort, inclusion, love,
of the other people in the home was using
in MMSE score over the control group. Studies identity and occupation. Mr A’s unsettled
a doll and finding comfort in doing so.
have demonstrated improved cognitive functions, behaviour might have a result of any of
Unexpectedly, one day Mr A found the doll
executive function (Baker 2010), attention and these needs being unmet. Doll therapy is an
and started to walk around the home with
attempt to meet these needs.
information processing (Lautenschlager 2008; it, talking to and cradling it. He appeared to
Vreugdenhil 2012) and improved physical health find great comfort in the doll and it became As it is difficult to assess how people
(Heyn 2004). his constant companion. One evening staff will respond to dolls, there are guidelines
found him sleeping on the edge of his (James 2006) about their use which
Other activity-based approaches bed where he had made a cradle from his should always be considered before
blankets for the doll. The doll met some implementation. The doll should be available
Occupation is described by Kitwood (1997) as one need within him that was not satisfied for the person to engage with themselves
of the main psychological needs of people with by other interventions or by prescribed rather than given to the person when they
dementia and by Perrin (1997) as the severest loss pharmacological agents: he was relaxed, do not react well. In addition, if doll therapy
in dementia. Lack of occupation leads to sensory showed pleasure and his periods of distress is identified as a possible intervention, its
deprivation, boredom, isolation and low mood abated. It was not anticipated by any of the purpose should always be explained to the
(Brechin 2013). Activity covers a diverse range of staff that this man would even contemplate family first.
interventions, and studies have looked at particular

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Patel et al

doll therapy in dementia in 2006. They found that

people who used dolls appeared less anxious, more
BOX 4 Example of validation
active and more content (James 2006). Mackenzie Patient: ‘Where is my coat? It’s raining out there and I
et al (2006) and Ellingford et al (2007) showed need to be leaving soon.’
similar results, indicating that there is a place for Staff: ‘Your coat... Um... Not sure Henry. Come on, we’ll
doll therapy in dementia care. However, Stevenson go and look for it.’
and colleagues (2010) stressed the need for caution
Patient: ‘Lots to do today, you know. Have to get my hair
as not all people respond well to it. Following cut, pick up the kids...’
their earlier work, Mackenzie and colleagues
Staff: ‘Right, well, you do have a lot to do... It seems you
(2007) developed guidelines for using dolls with
like to run around and keep busy.’
people with dementia because of the ethical issues
Patient: ‘I always have done. Don’t like to sit around, you
associated with it.
know.’
Reminiscence therapy
Reminiscence therapy usually takes place in a
group setting and makes use of photographs, music experience we may be able to better communicate
or video recordings and other objects to trigger with them and reduce their distress (Box 4).
personal memories. It has been used in the treat­ Developed between 1963 and 1980 by Naomi Feil
ment of other disorders, such as depression. Douglas – a social worker and author of two books (The Feil
et al (2004) noted the paucity of high-quality Method (Feil 1982) and Validation Breakthrough
studies, but in 2007 a multicentre, pragmatic (Feil 1993)) – the aim of the approach was to remedy
randomised controlled trial (REMCARE) set out what she felt was lacking in reality orientation. Its
to examine the effectiveness and cost-effectiveness principles are not unique and are shared by other
of reminiscence therapy against treatment as person-centred approaches:
usual (Woods 2012). Unfortunately, the authors of
•• all people are valuable, no matter how
the study concluded that reminiscence therapy was
disoriented they are;
not an effective intervention in terms of quality
•• painful feelings that are expressed, acknowledged
of life or psychological distress for caregivers and
and validated by a trusted listener will diminish.
was possibly worse for the latter outcome. They
reported that those who continued with the study •• Painful feelings that are ignored or suppressed
as planned to 3 months and 10 months showed will gain strength (Feil 1993).
some improvement in autobiographical memory, Validation therapy has at its centre 14 techniques
but this was accompanied by their caregivers including (but not limited to) the use of non-
reporting greater levels of stress. threatening factual words to build trust – ‘who’,
‘what’, ‘where’, ‘when’ and ‘how’, but not ‘why’ –
Cognitive stimulation therapy rephrasing the person’s speech to them, taking
Cognitive stimulation therapy is a group therapy advantage of ambiguity such as using ‘they’, ‘he’,
which aims to stimulate and engage patients with ‘she’ or ‘it’ to respond to their conversation and
mild to moderate dementia. Each session follows a using a clear, low, loving tone of voice (Feil 1993).
general theme or activity chosen from a list by the In a Cochrane review, Neal et al (2003)
group, such as physical games, being creative and concluded that, owing to the limited number of
current affairs. It was developed following a review trials and the small numbers of participants, there
of reality orientation therapy (Spector 2000) and was insufficient evidence to allow firm conclusions
was recommended in the NICE guidelines for about the efficacy of validation therapy on the
dementia (National Collaborating Centre for outcomes of behaviour, cognition, mood and
Mental Health 2007). A systematic review by activities of daily living for people with dementia.
Aguirre and colleagues (2013) showed significant In their 2009 update, Neal et al carried out a
improvements in cognition and quality of life, but further search to review any new studies, only
not on other specific measures of BPSD. They finding one study, which was later deemed not
also acknowledged that there was currently a lack suitable as the intervention included reminiscence
of evidence for the long-term effects of cognitive therapy as well as validation therapy. We cannot
stimulation therapy. locate any further studies on validation therapy.
The challenges for research are in determining
Validation therapy the components of validation that are effective for
This therapy is based on the idea that in accepting given outcomes, which should include the difficult-
the reality and personal truth of another’s to-measure outcomes of well-being and quality of

344 Advances in psychiatric treatment (2014), vol. 20, 340–349  doi: 10.1192/apt.bp.113.011957
 Psychosocial interventions for dementia

2010) was found by the authors of the review, but

BOX 5 What psychiatrists can do to promote this did show ‘promising’ results in self-reported
psychosocial interventions
measures of goal performance in the short term.
Psychosocial interventions are difficult to implement, for A systematic review by Gates and colleagues
both cultural and economic reasons (Lawrence 2012), but (2011) concluded that cognitive exercises could
our opinion, psychiatrists can take a number of steps to produce moderate to large improvements in
promote them: memory outcomes. However, this training was
• keep abreast of the literature, thereby developing a for adults with mild cognitive impairment ‘at
sense of the challenges and directions being taken in risk of developing dementia’, and reliability is
this field unclear owing to the quality of the trials and lack
• have frank discussions with staff at care homes of statistical synthesis. The authors highlight the
regarding the practicalities (benefits and difficulties) of need for more robust studies.
introducing, for example, music therapy for residents
• engage with local organisations that deliver life story Carer-focused interventions
work and animal-assisted therapy The range of behaviours encompassed by BPSD
• carry out an interventional study to measure behaviour- (Box 6) (as opposed to cognitive decline or
al changes before and after introduction of a psycho­ physical dependence on others) has been found
social intervention, providing a unique insight into what to impose the greatest burden on caregivers and
appears to work for the patients and staff in their care predict their decision to seek residential or nursing
• set up a post-diagnostic support group for their patients care for a family member with dementia (Brodaty
and carers; nursing and support staff would run the 2012). Caregivers could therefore be an effective
group, but the treating psychiatrist would actively medium for delivering interventions to minimise
oversee and modify it these symptoms.

Interventions in the community

life, which so far have not been included. In this Brodaty & Arasaratnam (2012) carried out a meta-
way, the evidence-based components of validation analysis of the effectiveness of family caregiver
therapy might successfully be incorporated into interventions on the management of BPSD in
other therapies (Neal 2003). Common to all people living in the community. Twenty-three
psychosocial interventions, we must then deal studies (of which 16 were randomised controlled
with the challenges of their implementation into trials) showed largely positive or partially positive
clinical practice (Box 5). results. Interventions included education for
caregivers (e.g. planning for emergencies, legal
Cognitive training and financial issues), activity planning and
Cognitive training – involving guided practice environmental design, enhancing support for
on a set of tasks and cognitive rehabilitation, caregivers (e.g. internet or telephone support),
individualised techniques or compensatory self-care techniques for caregivers (e.g. music
strategies – is designed to assist memory therapy, stress management) and exercise. The
impairment and other cognitive difficulties. effects were noted to be at least comparable to
Clare & Woods’ review in 2003 demonstrated those of antipsychotics. The authors concluded
no significant benefits from cognitive training, that successful interventions involved 9–12 home
stating that it was impossible to draw any sessions tailored to the needs of the person with
conclusions as study quality was limited. A dementia and the caregiver, delivered over 3–6
more recent review (Baher-Fuchs 2013) aimed months, interspersed with telephone sessions
to evaluate efficacy of these interventions with and subsequent individual or group telephone
people with mild Alzheimer’s disease or vascular
dementia. The authors evaluated 11 randomised
BOX 6 Behavioural and psychological
controlled trials and found that cognitive training
symptoms of dementia (BPSD)
was not associated with positive or negative
effects with reference to the outcomes and, again, • Depression • Pacing
methodological quality was low to moderate. • Anxiety • Wandering
The authors concluded that evidence is limited,
• Apathy/Indifference • Agitation
with no significant benefits of cognitive training,
acknowledging the lack of adequate measurement
• Delusions • Disinhibition
tools to capture benefits. Only one randomised • Hallucinations • Euphoria
controlled trial of cognitive rehabilitation (Clare

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Patel et al

follow-ups. The meta-analysis does not answer studies, showed that educational and support
questions about the optimal duration, frequency programmes for caregivers reduced caregiver
and setting of interventions at a practical level. burden when compared with standard care.
These will be defined questions for future research.
Environmental interventions
Post-diagnostic support Lawton (1990) recognised the role of the environ­
The National Dementia Strategy (Department of ment, acknowledging the vital nature of designing
Health 2009) identifies the need for good-quality, environments to meet the needs of people with
structured support after diagnosis. There are dementia, but describing the challenges in terms
various models of post-diagnostic support for of robust research design to measure efficacy
carers, but most are psychoeducational in nature, and impact on quality of life. Zeisel et al (2003)
providing support for 6–8 sessions. Research by demonstrated an association between behaviour
Whitlatch and colleagues (2005) demonstrate that and environmental design features, describing the
people in the early stages of dementia are often as potential the environment has for contributing
aware of the practical implications and problems to improvements in the symptoms of dementia
as caregivers. Robinson et al (2005) suggest by being comforting, safe and understandable.
that a support group for the person and their The physical environment can help people with
potential carer may provide the greatest benefit dementia achieve their potential, avoid increased
for both parties. disability and enrich life quality (Davis 2009).
A systematic review by Marim and colleagues Although the physical environment is important,
(2013), including seven randomised clinical so too is the psychosocial environment, preserving
personhood, reducing the need for antipsychotic
medication and improving quality of life
BOX 7 Measuring outcomes in psychosocial interventions research: (Werezak 2003).
the hurdles
The principles of dementia-friendly environ­
Psychosocial interventions do not lend Sample size and study duration ments are now widely recognised. Bicket and
themselves well to the gold standard Very few studies in Schwarzbach et al ‘s
colleagues (2010) indicated that the physical
randomised controlled efficacy trials used review had more than 200 patients; the environment in assisted-living facilities probably
for pharmacological interventions. In duration of studies ranged from 1 h to 52 affects neuropsychiatric symptoms and quality
addition to reviewing the findings from two weeks (they do not report an average). of life. Parker et al (2004) recommend that there
health technology assessments on should be a balance between choice and control,
non-pharmacological interventions for Comparators
physical support, normalness and authenticity,
dementia in Germany (German Institute for Many studies do not define ‘standard care’, comfort, cognitive support and personalisation as
Quality and Efficacy in Health Care 2009; which will be different across studies.
these are all associated with increased quality of
Rieckmann 2009), Schwarzbach et al  (2012) Furthermore, staff’s awareness that a study
life. Privacy reduces aggression and agitation and
provide an insightful and extremely clear is being carried out may mean that patients
analysis of the methodological problems improves sleep (Morgan 2004).
in the standard care arm receive a change
encountered by research into non- in their usual care as staff increase their
pharmacological interventions, as well as engagement with them. Measuring outcomes of psychosocial
providing some suggestions for ongoing Even if there is a good degree of matching interventions
research. for patients taking medication, one might A commentary by Kolanowski & Hill (2013) on
Inclusion criteria argue that it may reduce the patient’s the Brodaty et al meta-analysis raises worthwhile
ability to derive benefit from psychosocial points. Kolanowski & Hill report that the
Studies use different tools to make a
interventions or that it may be harder for meta-analysis followed the PRISMA (Preferred
diagnosis – how comparable then are the
a psychosocial intervention to show an Reporting Items for Systematic Reviews and
studies?
additional benefit.
Meta-Analysis) statement guidelines (with a few
Interventions themselves
Clinical end-points (outcomes) exceptions), increasing confidence in the validity
Interventions with the same name may,
In pharmacological research clinical end- of their results. These guidelines help authors
in practice, be applied very differently, so
points are requested by drug authorisation improve the quality of their reporting for studies
treatments even with the same name cannot
always be compared. Some treatments may agencies. In non-pharmacological research, of this type. Kolanowski & Hill feel that current
have been applied as a major departure there is currently little guidance and studies measures of BPSD lack precision, meaning that
from the usual delivery of care; others with may be using non-validated questionnaires, they might not pick up on a change in outcome.
the same name may have been used for only leading to problems in interpretation of the They also reiterate that quality-of-life indicators
a set number of sessions. Again, comparison outcomes the produce. may be better measures and this appears to be an
is not ideal, but does occur in practice, Schwarzbach et al  remind us that the lack of emerging theme that we have noted. Kolanowski
obscuring true results. evidence should not imply lack of efficacy. & Hill also report that reliance on randomised
controlled trials as the sole source of evidence

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 Psychosocial interventions for dementia

References
BOX 8 Useful resources
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MCQs 3 Which of these statements regarding d Forbes et al looked at light therapy of various
Select the single best option for each question stem post-diagnostic support is false? intensities and timings
a research supports a structured approach to e Burns et al showed that light therapy for 2
1 Doll therapy:
post-diagnostic support weeks at 10 000 lux from 14.00 h to 16.00 h
a is based on Piaget’s developmental theory
b Whitlatch et al found that people in the early reduced agitation on the CMAI.
b is a gender-specific intervention
c can reduce anxiety and increase activity levels stages of dementia are often unaware of the
d is a harmless approach that can be used with diagnosis 5 Regarding non-pharmacological
everyone c Robinson et al felt that support should be interventions:
e is not an effective alternative to medication. provided for the carer and the person with a they should be tried if medication is
dementia together unsuccessful
d supporting carers at the start can prevent b they are not effective as the evidence base is
2 Regarding reminiscence therapy and life
crises occurring weak
story work:
a the REMCARE trial showed modest benefits for e the National Dementia Strategy states that c cognitive stimulation therapy is a useful
most patients everyone should have post-diagnostic support. intervention for everyone with dementia
b the REMCARE trial was neither positive or d they are a cheaper alternative to medication
negative for caregivers 4 With regard to light therapy: e they should be about the general well-being of
c the REMCARE trial was a cohort-based study a studies suggest that the timing and intensity of the person rather than just minimising BPSD.
d life story work is based partly on the principles the light therapy are crucial to its efficacy
of reminiscence therapy b the internal biological clock is least sensitive
e McKeown et al ’s 2006 randomised controlled to light
trial concluded there were ‘far reaching’ c Barrick et al showed that agitation was lower
benefits. under high-intensity morning light therapy

Advances in psychiatric treatment (2014), vol. 20, 340–349  doi: 10.1192/apt.bp.113.011957 349
Psychosocial interventions for dementia: from evidence to
practice
Bhamini Patel, Mark Perera, Jill Pendleton, Anna Richman and Biswadeep Majumdar
APT 2014, 20:340-349.
Access the most recent version at DOI: 10.1192/apt.bp.113.011957

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