The Gerontologist

cite as: Gerontologist, 2022, Vol. 62, No. 4, e253–e264

doi:10.1093/geront/gnaa207
Advance Access publication December 16, 2020

Review Article

Person-Centered Care in Persons Living With Dementia:

A Systematic Review and Meta-analysis
Kyung Hee Lee, PhD, GNP, MPH, RN,1,2, Ji Yeon Lee, GNP-BC, MSN, RN,1 and Bora Kim,
MSN, RN1,*
Yonsei University College of Nursing, Seoul, South Korea. 2Mo-Im Kim Nursing Research Institute, Seoul, South Korea.
1

*Address correspondence to: Bora Kim, MSN, RN, Yonsei University College of Nursing, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul 03722, South Korea.
E-mail: [email protected]

Received: August 21, 2020; Editorial Decision Date: November 30, 2020

Decision Editor: Patricia C. Heyn, PhD, FGSA, FACRM

Abstract
Background and Objectives: The concept of person-centered care has been utilized/adapted to various interventions to
enhance health-related outcomes and ensure the quality of care delivered to persons living with dementia. A few systematic
reviews have been conducted on the use of person-centered interventions in the context of dementia care, but to date, none
have analyzed intervention effect by intervention type and target outcome. This study aimed to review person-centered
interventions used in the context of dementia care and examine their effectiveness.
Research Design and Methods: A systematic review and meta-analysis were conducted. We searched through 5 databases
for randomized controlled trials that utilized person-centered interventions in persons living with dementia from 1998 to
2019. Study quality was assessed using the National Institute for Health and Clinical Excellence checklist. The outcomes
of interest for the meta-analysis were behavioral and psychological symptoms in dementia (BPSD) and cognitive function
assessed immediately after the baseline measurement.
Results: In total, 36 studies were systematically reviewed. Intervention types were reminiscence, music, and cognitive
therapies, and multisensory stimulation. Thirty studies were included in the meta-analysis. Results showed a moderate
effect size for overall intervention, a small one for music therapy, and a moderate one for reminiscence therapy on BPSD
and cognitive function.
Discussion and Implications: Generally speaking, person-centered interventions showed immediate intervention effects
on reducing BPSD and improving cognitive function, although the effect size and significance of each outcome differed by
intervention type. Thus, health care providers should consider person-centered interventions as a vital element in dementia
care.
Keywords: Behavioral and psychological symptoms in dementia, Cognitive function, Reminiscence therapy

Cognitive impairment is a hallmark symptom of de- are major sources of caregiver burden and reasons to
mentia; more than 90% of persons living with dementia consider institutionalization for this population group
experience behavioral and psychological symptoms in (Brodaty et al., 2014; Eska et al., 2013; Voutilainen et al.,
dementia (BPSD; Ballard & Corbett, 2010). Additional 2018). Relatedly, person-centered care is recommended as
studies showed that common experiences of people living a first line of choice to manage BPSD (Kales et al., 2019)
with dementia are BPSD (Zhao et al., 2016). In particular, and to provide care for persons living with cognitive
a study highlighted that all of these common occurrences impairments.

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e254 The Gerontologist, 2022, Vol. 62, No. 4

Person-centered care refers to care in which the Method

“individual’s values and preference are elicited and, once
Protocol and Registration
expressed, guide all aspects of their health care, supporting
This systematic review was conducted in accord-
their realistic health and life goals” (The American
ance with the PRISMA (Preferred Reporting Items for
Geriatrics Society Expert Panel on Person-Centered Care,
Systematic Reviews and Meta-Analyses) guidelines
2016, p. 16). This concept of care has been emphasized
(Moher et al., 2009; Supplementary Table 1) and the
as an essential element to help maintain care quality; in
protocol for this systematic review was registered at
the United States, to encourage person-centered care, the
International Prospective Register of Systematic Reviews
Center for Medicare & Medicaid Services launched a
(ID: CRD42020169376).
regulation that enforces the documentation of resident’s
preferences in long-term care contexts (U.S. Department of
Health and Human Services, 2015). In dementia care, the Search Strategies
term “person-centered care” was first used in 1998, by Tom
Kitwood (1988), and it is now considered a fundamental We searched the following electronic databases: PubMed,
part of dementia care quality (Fazio et al., 2018). the Cumulative Index to Nursing and Allied Health
Since the introduction of this term in the dementia Literature (CINAHL), PsycINFO, Embase, and the
care field of research, many studies using person-centered Cochrane Database of Systematic Reviews. As mentioned,
care have been published. Specifically, two review papers the term “person-centered care” was introduced in dementia
have synthesized the evidence on the effects of person- research in 1998; thus, we included articles published in
centered care in persons living with dementia (Chenoweth English from January 1998 to September 2019. The search
et al., 2019; Li & Porock, 2014); nonetheless, they did strategies included three key terms: person-centered care,
not provide the specific effect size of the person-centered dementia, and randomized controlled trial (RCT). Detailed
interventions. Partially filling in this research gap, a re- descriptions are presented herein:
cent meta-analysis that analyzed 16 studies reported the 1. For person-centered care, the combinations of (“person”
overall effect size of person-centered care interventions or “patient” or “resident” “client” or “relationship”)
for four specific outcomes (i.e., agitation, neuropsychiatric AND (“centered” or “directed” or “oriented” or “fo-
symptoms, depression, and quality of life); results showed cused”) AND (“care” or “intervention”) were used. We
that person-centered interventions were significantly ef- also used potential key terms that referred to specific
fective on reducing agitation, neuropsychiatric symptoms, types of interventions using person-centered care: “de-
and depression, and on improving quality of life (Kim & mentia care mapping” OR “touch therapy” OR “music
Park, 2017). However, Kim and Park (2017) did not ex- therapy” OR “aroma therapy” OR “light therapy” OR
amine which intervention was effective for each studied “validation therapy” OR “Montessori-based activities”
outcome. OR “reminiscence” OR “emotion-oriented care” OR
This lack of examination provides for an important “sensory stimulation” OR “snoezelen” OR “ability-
research gap, because various studies have applied dif- focused approach.”
ferent kinds of interventions (e.g., music, reminiscence, 2. For dementia, the terms “dementia” OR “Alzheimer
cognitive, and multisensory therapies) using the concept Disease” were used.
of person-centered care, and there are huge differences be- 3. For RCT, the terms “randomized controlled trial” OR
tween each kind; for instance, in music therapy, choosing “controlled clinical trial” OR “randomized” OR “ran-
which music to play during therapy is done based on domly” OR “trial” were used.
individuals’ preferences, whereas in cognitive therapy, this
type of customization is done based on individuals’ cogni-
tive abilities. Namely, the intervention effect might differ Selection of Studies
by intervention type and target outcome. Thus, it appears
To prevent the deletion of relevant articles, two reviewers
important to understand not only the overall effect of
used an online program (http://rayyan.qcri.org) to inde-
person-centered interventions, but also the effect of each
pendently assess the titles and abstracts of the articles that
intervention type in persons living with dementia.
were identified by the search strategy. The eligible studies
Thus, it seems important to evaluate whether person-
were included in the full-text review only after consensus
centered interventions are effective for improving cognitive
was reached; if there was a disagreement between the two
function and reducing BPSD in persons living with de-
reviewers regarding eligibility, a third reviewer intervened.
mentia. Accordingly, this study aimed to: (a) systematically
The analyzed studies were included based on the following
review studies using person-centered care and (b) conduct
criteria:
a meta-analysis to examine the overall effectiveness and
the effectiveness of each type of person-centered interven- 1. Participants: Studies with a study population comprising
tion on BPSD and cognitive function of persons living with participants who were diagnosed with any type of
dementia. dementia.
The Gerontologist, 2022, Vol. 62, No. 4 e255

2. Intervention: Studies that applied the concept of person- conducted with the intervention of a third author until con-
centered care, which was defined as “promoting patient sensus was reached.
involvement and individualization of care” based on a The NICE methodology checklist comprised 14 items
previous study (Robinson et al., 2008). Moreover, we regarding four biases (i.e., selection, performance, attrition,
ensured that studies utilized this concept when there and detection biases) that could occur in RCTs. Checklist
were phrases such as: “Meet individualized needs,” items were answered based on a four-item scale: “yes,”
“maintain the personhood,” “understanding of per- “no,” “unclear,” and “not applicable.” An item was rated
sonal experience,” “enabling them to make choices as “yes” when the study minimized the risk of bias for that
about their care,” and “respecting the person’s beliefs, item, as “no” when the study did not meet the condition
values, and preferences” (Robinson et al., 2008). proposed by the item and had a potentially high risk of
3. Comparison: Studies in which participants were bias, as “unclear” when the item was not reported or if the
assigned to either an experimental intervention group report was unclear, and as “not applicable” when the item
or a control group with traditional care. was not applicable for the study.
4. Outcomes: Studies that measured the effects of We allocated points to individual studies according to
interventions in cognitive function and BPSD (e.g., de- how items were rated: Two points were allocated if the item
pression, agitation, neuropsychiatric symptoms). was rated as “yes,” one point if “unclear,” and no points if
5. Study design: To ensure study homogeneity, we only in- “no.” Then, we calculated the average risk of bias for each
cluded RCTs. study by summing up the points and dividing this sum by
the number of checklist items. We excluded the “not appli-
Among the eligible studies, we applied an additional cri-
cable” items in the point rating and calculation. Finally, we
terion for eligibility to the meta-analysis procedure: The
classified the overall risk of bias for a study as high (<1),
quantitative results of the studies had to include adequate
moderate (1 to <1.5), and low (≥1.5).
statistical values (e.g., mean, standard deviation, and me-
dian with range) for computing an effect size.

Data Analysis
Data Extraction All data analyses were performed using Comprehensive
We extracted outcome measures that included baseline and Meta-Analysis software, version 3 and Review Manager
post intervention results. If a study had multiple measure- (RevMan) software, version 5. To decrease the effects
ment time points, to ensure that we would identify only the of between-study heterogeneity (DerSimonian & Laird,
effect size of the intervention that was of interest to our 1986), we evaluated the pooled treatment effects using
review, we compared the results that were measured imme- random-effects models. Because the included studies used
diately after the baseline measurement. different measures to assess the outcomes of interest, the
Additionally, if the study had more than three interven- standardized mean difference (SMD) was calculated with a
tion arms, we paired them as “person-centered care versus 95% confidence interval (CI).
usual care interventions,” based on what the respective We evaluated the effect size in accordance with Cohen’s
study described as the person-centered intervention. To ex- criteria: An SMD of ≥0.20 and <0.50 was considered small;
amine the effectiveness of person-centered interventions in ≥0.50 and <0.8 was moderate; and ≥0.8 was large (Cohen,
persons living with dementia through the meta-analysis, 1992, 2013). The direction of the effect size was defined ac-
after reaching consensus among the three reviewers, we cording to the methodology utilized in the measurement of
divided the studies into four categories: (a) music therapy each outcome; to be included in the meta-analysis, an out-
(i.e., doing movements accompanied by music or listening come needed to appear in more than two studies. To con-
to a preferred music); (b) reminiscence therapy (i.e., the firm between-intervention heterogeneity according to the
recalling and sharing of personal memories or experiences); outcomes of interest, we conducted additional subgroup
(c) cognitive therapy (i.e., general stimulation using con- analyses using the I2 value.
centration, thinking, or learning); and (d) multisensory
stimulation (i.e., touch, and additional sensory stimulations
to people’s vision, audition, and smell). Results
Figure 1 illustrates study selection procedures. The in-
itial search in five databases generated 2,710 articles.
Quality Assessment After removing duplicates, 1,817 articles remained; after
The quality of the studies was assessed by two independent reviewing the titles and abstracts, 107 articles remained.
authors who used the National Institute for Health and Then, we excluded 71 articles through full-text review;
Clinical Excellence (NICE) checklist (National Institute for the reasons for exclusion are described herein: 34 articles
Health and Care Excellence, 2012). If there was a disagree- did not use a control group with usual care; 19 articles
ment between the two authors, further discussions were did not provide a definition for person-centered care that
e256 The Gerontologist, 2022, Vol. 62, No. 4

Figure 1. Flow diagram of study selection.

concurred with our definition; seven articles did not use (n = 11; e.g., music listening, singing, or song writing),
a RCT design; six articles did not include outcomes of in- multisensory therapy (n = 7; e.g., Montessori-based ac-
terest; three articles did not focus on persons living with tivities), and cognitive therapy (n = 4) were also included.
dementia as the study population (e.g., they focused on The persons who conducted the interventions varied by
the caregivers, families, and staff); and two articles were intervention type: nurses (n = 8), music therapists (n = 8),
published abstracts. nursing home staff (n = 6), psychologists (n = 6), occu-
Consequently, 36 articles were included in the system- pational therapists (n = 5), and so on. The duration (i.e.,
atic review. Among them, six articles were not included in minutes per session) of each intervention ranged from 10
the meta-analysis because they did not provide usable data to 90 min, and the frequency (i.e., number of sessions per
for computing effect size. Therefore, 30 articles including week) ranged from 1 to 21.
2,551 participants underwent meta-analysis. Among the selected studies, the effectiveness of the
interventions was assessed by the following outcomes: agi-
tation (n = 9), cognition (n = 21), depression (n = 20), and
Characteristics of the Included Studies neuropsychiatric symptoms (n = 10). Particularly, cognitive
Table 1 describes the characteristics of the included studies; therapies evaluated depression (n = 3) or cognition (n = 2);
the included studies were published from 1998 to 2019: music therapies evaluated cognition (n = 6), neuropsychi-
one in 1998, nine from 1999 to 2010, and 26 studies from atric symptoms (n = 4), agitation (n = 4), or depression
2011 to 2019. Participants’ mean age ranged from 69.1 to (n = 3); multisensory stimulation mainly evaluated agita-
94.9 years in the studies. tion (n = 5) or depression (n = 3); reminiscence therapies
The mean sample size (including intervention and con- mostly measured cognition (n = 11) or depression (n = 10).
trol groups) was of approximately 88 persons living with Moreover, the studies used different tools to measure
dementia, ranging from 17 to 646. The percentage of fe- these outcomes. For agitation, most studies used the
male participants in each study ranged from 40% to 100%. Cohen-Mansfield Agitation Inventory (n = 7). For cog-
Most studies comprised two arms (n = 27), but could in- nition, almost all studies used the Mini-Mental State
clude up to four. Most studies were conducted in Japan Examination (MMSE; n = 20). For depression, studies used
(n = 5), followed by the United Kingdom (n = 4), Taiwan the Cornell Scale for Depression in Dementia (n = 14),
(n = 4), and the United States (n = 4). the Multidimensional Observation Scale for Elderly
The types of interventions varied widely; reminiscence Subjects (n = 3), the Geriatric Depression Scale (n = 2),
therapy (n = 14) was the most frequent, but music therapy and the Hospital Anxiety and Depression Scale (n = 1).
Table 1. Characteristics of Included Studies

Sample size (mean age)

Intervention Duration PCC

Study; country Dementia type Intervention group Control group % of female (frequency)c Main instructor Outcome (instrument) definitione

Amieva et al. (2016); AD Personal CT 156 (78.90) 153 (78.70) 60.22 90 (1) Psychologist NPS (NPI) 2
France Group CT 168 (78.50)
RT 169 (78.80)
Aslakson (2010); Dementia MT 21 (85.00) 19 (86.68) 90.00 35 (3) Music therapist Agitation (WAI) 1
United States
Bailey et al. (2017); Dementia RT 26 (84.35) 25 (83.92) 90.20 30 (2) Psychologist Depression (CSDD) 1, 2
The Gerontologist, 2022, Vol. 62, No. 4

United States
Bakshi (2004); Dementia MSS 20 (78.00) 20 (78.00) 40.00 35 (3) Occupational Agitation (CMAI) 2
Canada therapist
Chu et al. (2014); Dementia MT 49 (82.00a) 51 (82.00a) 53.00 30 (2) Music therapist Cognition (MMSE), depression 1
Taiwan (CSDD)
Clare et al. (2010); AD, mixed Personal CT 22 (76.32) 22 (78.18) 58.82 60 (1) Occupational Depression (HADS) 2
England therapist
Duru Aşiret & Kapucu AD RT 31 (81.83) 31 (82.26) 67.74 35 (1) Nurse Cognition (MMSE), depression 1
(2016); Turkey (GDS)
Hong & Choi (2011); AD, VD, PDD MT 15 (78.30a) 15 (78.30a) 93.33 60 (1) Music therapist Cognition (MMSE) 1
Korea
Hsieh et al. (2010); Dementia RT 29 (77.90) 32 (77.25) 40.98 45 (1) Nurse Depression (CSDD) 1
Taiwan
Hsu et al. (2015); AD, VD, DFT, DLB, MT 9 (84.56) 8 (82.50) 94.12 30 (1) Music therapist NPS (NPI) 1
England mixed, UNS
Hutson et al. (2014); AD, VD, DLB, mixed, MSS 21 (86.80a) 18 (86.80a) 86.11 50 (2) Staff Depression (CSDD), NPS (NPI) 1
England UNS
Ito et al. (2007); Japan VD RT 18 (82.90) 17 (82.10) 61.76 60 (1) Specialistd Cognition (MMSE) 1, 2
Kallio et al. (2018); AD, VD, PDD, DLB, CT 76 (82.60) 71 (83.60) 72.00 45 (2) Psychologist Cognition (MMSE) 2
Finland UNS
Lai et al. (2004); Dementia RT 36 (86.20) 30 (86.80) 67.44 30 (1) RA Cognition (MMSE) 1, 2
Hong Kong
Lawton et al. (1998); Dementia MSS 88 (NA) 94 (NA) NA NA Nurse Depression (MOSES) 1, 2
England
Lök et al. (2019); Turkey AD, unspecified RT 30 (NA) 30 (NA) 56.67 60 (1) Nurse Cognition (MMSE), depression 1, 2
(CSDD)
Lopes et al. (2016); Dementia RT 20 (83.85) 20 (83.62) 77.50 35 (1) Nurse Cognition (MoCA), depression 1
Portugal (CSDD)
e257
Table 1. Continued
e258

Sample size (mean age)

Intervention Duration PCC

Study; country Dementia type Intervention group Control group % of female (frequency)c Main instructor Outcome (instrument) definitione

Lyu et al. (2018); China AD MT 97 (68.90) 95 (69.90) 59.03 35 (14) Music therapist Cognition (MMSE), NPS (NPI) 1
Maseda et al. (2014); Dementia MSS 10 (87.20) 10 (86.70) 95.00 30 (2) Psychologist or Agitation (CMAI), cognition 1
Spain occupational (MMSE), depression CSDD),
therapist NPS (NPI)
Nakamae et al. (2014); AD, VD RT 17 (84.76) 19 (87.16) 100.00 40 (1) Occupational Cognition (MMSE), depression 1, 2
Japan therapist (CSDD)
Pérez-Ros et al. (2019); Dementia MT 47 (80.06) 72 (80.80) 50.85 60 (5) Staff Cognition (MMSE), depression 1
Spain (CSDD)
Raglio et al. (2015); Italy Dementia MT 40 (81.00) 40 (82.40) 78.33 30 (2) Music therapist Depression (CSDD), NPS (NPI) 2
Ridder et al. (2013); Dementia MT 21 (82.17) 21 (80.20) 69.00 33.8 (2) Music therapist Agitation (CMAI) 1
Denmark and Norway
Sánchez et al. (2016); Dementia MSS 11 (86.40) 10 (82.30) 78.10 30 (2) Occupational Agitation (CMAI), cognition 1, 2
Spain therapist (MMSE), depression
(CSDD), NPS (NPI)
Shiltz et al. (2018); Dementia MT 47 (80.00) 45 (76.00) 52.17 30 (3) Staff Agitation (CMAI), cognition 1
United States (MMSE)
Staal et al. (2007); Dementia MSS 12 (80.33) 12 (72.00) 66.67 30 (3) RA Agitation (PAS) 1, 2
United States
Tadaka & Kanagawa Dementia RT 30 (84.20) 30 (82.40) 75.00 90 (1) Specialistd Cognition (MMSE), depression 1, 2
(2007); Japan (MOSES)
Tanaka et al. (2017); AD, VD, DLB, Personal CT 20 (86.00) 20 (86.50) 90.00 60 (2) Staff Cognition (MMSE), depression 2
Japan mixed, UNS (GDS)
Group CT 20 (84.90) 20 (2)
Van Bogaert et al. AD RT 41 (83.00) 41 (85.00) 82.93 45 (2) Nurse Cognition (MMSE), depression 1, 2
(2013); Belgium (CSDD), NPS (NPI)
Van Bogaert et al. Dementia RT 29 (84.00b) 31 (84.00b) 80.00 45 (2) Nurse Cognition (MMSE), depression 1, 2
(2016); Belgium (CSDD), NPS (NPI)
van der Ploeg et al. Dementia MSS 15 (78.10a) 29 (78.10a) 68.18 30 (2) Psychologist Agitation (CMAI) 1
(2013); Australia
Wang (2007); Taiwan Dementia RT 51 (79.76) 51 (78.92) 50.98 60 (1) Nurse Cognition (MMSE), depression 2
(CSDD)
Wang et al. (2018); AD MT 30 (70.40) 30 (69.10) 63.33 40 (21) Music therapist Cognition (MMSE), NPS (NPI) 1, 2
China
Weise et al. (2019); Dementia MT 10 (85.05a) 10 (85.05a) 80.00 30 (3.5) Staff Agitation (CMAI) 2
Germany
The Gerontologist, 2022, Vol. 62, No. 4
 The Gerontologist, 2022, Vol. 62, No. 4 e259

For neuropsychiatric symptoms, all studies used the

bodies; GDS = Geriatric Depression Scale; HADS = Hospital Anxiety and Depression Scale; MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment; MOSES = Multidimensional Observation Scale

Age of all participants. bMedian age. cDuration refers to the number of minutes per session and frequency refers to the number of sessions per week. dSpecialist refers to various types of therapists. ePCC definition (1 = pro-
Notes: AD = Alzheimer’s disease; CMAI = Cohen-Mansfield Agitation Inventory; CSDD = Cornell Scale for Depression in Dementia; CT = cognitive therapy; DFT = dementia of frontal lobe type; DLB = dementia with Lewy

for Elderly Subjects; MSS = multisensory stimulation; MT = music therapy; NA = not applicable; NPI = Neuropsychiatric Inventory; NPS = neuropsychiatric symptoms; PAS = Pittsburgh Agitation Scale; PCC = person-centered
definitione
Neuropsychiatric Inventory (n = 10). The included studies

PCC

1, 2
applied person-centered care interventions by promoting

1
participants’ involvement (n = 15), individualizing care
Outcome (instrument) (n = 8), or applying both concepts (n = 13).

Quality Assessment
Depression (MOSES)
Cognition (MMSE)

We evaluated all included studies by the NICE methodo-

logical checklist (Supplementary Table 2). Results showed
that 26 studies (72.2%) had a low risk of bias, 10 (27.8%)

care; PDD = Parkinson disease dementia; RA = research assistant; RT = reminiscence therapy; VD = vascular dementia; UNS = unspecified; WAI = Wisconsin Agitation Inventory.
had a moderate risk, and no study had a high risk of bias.
Thus, most included studies had high quality.
Control group % of female (frequency)c Main instructor

Effects of Intervention
Psychologist

Table 2 shows the overall effect size of the person-centered

Staff

interventions on BPSD and cognitive function by inter-

vention type. The overall effects of the interventions on
BPSD (SMD = −0.52, 95% CI: −0.67 to −0.36) and cog-
Duration

60 (2)
10 (1)

nitive function (SMD = 0.52, 95% CI: 0.27–0.76) were

moderate. Specifically, the subgroup analyses confirmed
the immediate effect of the interventions on reducing
BPSD and improving cognitive functions. Additionally,
between-subgroup comparisons showed heterogeneous
90.74
68.93

effects on BPSD (I2 = 66%) and cognitive function

(I2 = 73%).
For music therapy, the immediate effects on BPSD
26 (84.90)
50 (73.60)

(SMD = −0.33, 95% CI: = −0.48 to −0.18) and cognitive

Sample size (mean age)

function (SMD = 0.35, 95% CI: 0.01–0.69) were small.

Nonetheless, results confirmed that, regardless of the effect
size, music therapy reduced BPSD and improved cognitive
Intervention

28 (85.50)
53 (73.50)

function.
For reminiscence therapy, the immediate effects on
Intervention group

BPSD (SMD = −0.74, 95% CI: −1.02 to −0.47) and

cognitive function (SMD = 0.59, 95% CI: 0.27–0.91)
were both moderate. Thus, results confirmed that remi-
niscence therapy reduced BPSD and improved cognitive
function.
CT
RT

For cognitive therapy, the only outcome subgroup that

had enough cases to be included in the meta-analysis was
moting patient involvement, 2 = individualization of care).

that of depression; however, there was no significant effect

of cognitive therapy on depression (SMD = −0.21, 95%
Dementia type

mixed, UNS

CI: −0.53 to 0.11), and there was no heterogeneity among

AD, VD, DFT

cases (I2 = 0%).

AD, DFT

For multisensory stimulation, subgroup analyses

were used to explore the effect on two outcomes (i.e.,
depression and agitation); nevertheless, there were no
Yamagami et al. (2012);

significant effects of multisensory stimulation on depres-

Table 1. Continued

sion (SMD = −0.10, 95% CI: −0.37 to 0.16) or agita-

Wu & Koo (2016);

tion (SMD = −0.81, 95% CI: −1.71 to 0.09). However,

Study; country

there was a significant effect of the overall cases toward

favoring the use of multisensory stimulation therapies
Taiwan

Japan

(SMD = −0.48, 95% CI: −0.95 to −0.01), and there was

heterogeneity among cases (I2 = 75%). The forest plots
a
e260 The Gerontologist, 2022, Vol. 62, No. 4

Table 2. Meta-analytic Result of Person-Centered Intervention Effect

Variable k d 95% CI Z I2

Overall effect on BPSD 31 −0.52 −0.67, −0.36 6.60** 66

Overall effect on depression 19 −0.51 −0.71, −0.32 5.24** 63
Overall effect on NPS 7 −0.51 −0.84, −0.18 3.04** 77
Overall effect on agitation 5 −0.59 −1.13, −0.04 2.11* 68
Overall effect on cognitive function 15 0.52 0.27, 0.76 4.16** 73
MT effect on BPSD 9 −0.33 −0.48, −0.18 4.33** 0
MT effect on depression 3 −0.33 −0.56, −0.09 2.71** 0
MT effect on NPS 4 −0.35 −0.68, −0.03 2.13* 47
MT effect on agitation 2 −0.26 −0.80, 0.27 0.96 0
MT effect on cognitive function 5 0.35 0.01, 0.69 2.04* 68
RT effect on BPSD 13 −0.74 −1.02, −0.47 5.28** 77
RT effect on depression 10 −0.77 −1.03, −0.51 5.74** 59
RT effect on NPS 3 −0.69 −1.44, 0.05 1.82 90
RT effect on cognitive function 10 0.59 0.27, 0.91 3.60** 72
CT effect on depression 4 −0.21 −0.53, 0.11 1.30 0
MSS effect on BPSD 5 −0.48 −0.95, −0.01 2.01* 75
MSS effect on depression 2 −0.10 −0.37, 0.16 0.76 0
MSS effect on agitation 3 −0.81 −1.71, 0.09 1.76 83

Notes: k = number of comparisons; d = standardized mean difference calculated under random-effect model; I2 = heterogeneity statistic; Z = test statistic used to
derive the p value; BPSD = behavioral and psychological symptoms of dementia; CI = confidence interval; CT = cognitive therapy; MSS = multisensory stimulation;
MT = music therapy; NPS = neuropsychiatric symptoms; RT = reminiscence therapy.
*p < .05. **p < .01.

showing the effects of each intervention have been pro- Since the concept of person-centered care was first
vided as Supplementary Figures 1–5. introduced to the dementia context in 1998, it has been
applied to numerous studies. Although studies have ap-
plied person-centered care in different ways in the last
Discussion two decades, humanity is its essence (Li & Porock, 2014;
Our systematic review summarized the applied interventions Powers, 2005). Specially in the dementia care context, re-
and characteristics of various studies that utilized the con- specting patients and treating them as human beings that
cept of person-centered care. Considerable high-quality have the right to dignity and autonomy is very important
studies have applied person-centered interventions to because persons living with dementia are often treated
persons living with dementia. These interventions have as not having self-determination owing to the cogni-
utilized multidisciplinary experts, according to the nature tive impairments inherent to their condition. Relatedly, a
of each intervention and measurement tools suitable for study showed they can express emotions even during the
dementia, and consequentially contributed to improving later stages of dementia and that their psychological needs
BPSD and cognitive function of persons living with de- should be respected (Lee et al., 2013).
mentia. Our meta-analysis highlighted that the effect size To ensure that all studies applied person-centered care
of the interventions on BPSD and cognition differed by in- on their interventions, we used a definition set forth by a
tervention type. To the best of our knowledge, this was the prior study that was devoted to analyzing person-centered
first study to examine the effectiveness of person-centered care and its definitions (Robinson et al., 2008). As a result,
interventions on persons living with dementia by outcome we were able to include a sizable amount of studies in our
and intervention type; until now, only three reviews—in- analysis (n = 36). Specifically, our results showed that the
cluding one meta-analysis—have focused on the outcomes number of studies on the topic has increased in recent years
of interventions aimed at persons living with dementia worldwide, and that person-centered care was applied to
(Chenoweth et al., 2019; Kim & Park, 2017; Li & Porock, various intervention types (e.g., music, cognitive, and rem-
2014). Although these reviews have explored the effect of iniscence therapies, and multisensory stimulation). The
our analyzed interventions in our population of interest, increase in the number and scope of application of person-
they did not differentially consider intervention type. centered care may reflect a philosophical shift on dementia
Thus, our unique contribution to dementia research was care to consider an individual’s values and preferences,
to identify the effect size of each intervention type on the which is both meaningful and inspiring. Regarding quality,
outcomes of interest. over 72% of the studies were classified as low risk of bias,
The Gerontologist, 2022, Vol. 62, No. 4 e261

and no studies were classified as high risk of bias with re- dementia because it is usually designed to enhance cogni-
spect to their methodologies. Thus, the results from the in- tive function (Wilson, 2002), and the multisensory stimu-
cluded studies were deemed valid and reliable. lation studies in our review had a relatively smaller scale
Our meta-analysis revealed that person-centered compared to the others, which might have influenced the
interventions showed the immediate effects on reducing nonsignificant results. Furthermore, music therapy was
BPSD and improving cognitive function, but effect size the only intervention type that was effective to reduce
differed by intervention type. Specifically, reminiscence neuropsychiatric symptoms, indicating that listening to
therapy showed a moderate effect size, while music therapy a preferred music can promote relaxation (Lin et al.,
and multisensory stimulation had a small effect size. 2011).
Despite effect size differences, we speculated that music and
reminiscence therapies each had their own merits; music
therapy distracts people from their unpleasant emotions Study Limitations and Strengths
by musical stimulation and allows for the expression of Our study had some limitations that we would like to high-
people’s current emotions through musical methods (Chu light. First, it may have incurred reporting bias because we
et al., 2014), and reminiscence therapy uses empathy and only included studies published in the English language
interactions with others through the re-experience of past and from the main search engines that show up exclusively
memories to help people with their problems (Aşiret & scholarly journals and dissertations.
Kapucu, 2016; Hsieh et al., 2010; Lopes et al., 2016; Scales Second, although we endeavored to include all studies
et al., 2018). Specifically, expressing one’s thoughts or that utilized the concept of person-centered care, we ac-
feelings through the remaining memory (i.e., reminiscence knowledge that there may be studies that applied the
therapy) could be a meaningful activity to persons living concept and that were not included in our review; this is
with dementia; it might promote their self-understanding because we decided to include studies solely based on their
through communication with others and further improves descriptions of the interventions or of the intervention
ego-integrity by reconstructing their memories (Haight & components.
Burnside, 1993). However, we were not able to compare Third, the reviewed studies utilized a wide array of
whether the effect size of reminiscence therapy was bigger measurement tools, and there were instances in which the
than that of other interventions regarding BPSD owing same outcome was measured by different tools. Although
to study heterogeneity; thus, further and more elaborate we tried to overcome this limitation by calculating SMD,
studies are warranted to reveal whether this type of inter- interpretations regarding our results on the effect size of
vention is indeed superior in reducing BPSD. each outcome should be made with caution.
Moreover, our results emphasized that music and rem- Despite these limitations, our study also has strengths
iniscence therapies were effective in improving MMSE to be mentioned. First, we only included RCTs; this was
scores, namely, the cognitive function of people living done because RCTs are less likely to be influenced by
with dementia. This is in line with the finding that music confounding factors and bias, compared to observational
stimulates a number of brain regions and can help with or other types of experimental studies, thus conferring reli-
cognitive rehabilitation (Li et al., 2015; Lyu et al., 2018); ability to our study results. Moreover, to date, this was the
additionally, remembering and discussing past events (i.e., first meta-analysis to examine the effect of person-centered
core components of reminiscence therapy) could be benefi- interventions on persons living with dementia by interven-
cial for the rehabilitation of cognitive function of persons tion type and targeted outcome, to the best of our know-
living with dementia (Lök et al., 2019). ledge. Thus, this may be a valuable resource for researchers
Our results also showed that music and reminiscence endeavoring to know which person-centered intervention
therapies were effective in decreasing depression, whereas may be more effective for a specific health outcome.
cognitive therapy and multisensory stimulation did
not show statistically significant effects on depression.
This between-intervention difference may owe to what Conclusions
each intervention type focused on; for example, music Our results underlined that various types of person-
and reminiscence therapies have their main procedures centered interventions have been applied to reduce BPSD or
intricately related to individuals’/patients’ values improve cognitive function of persons living with dementia
and preferences (e.g., listing their preferred songs or in the past two decades (i.e., from 1998 to 2019). They
creating opportunities to communicate about one’s good also showed that person-centered interventions can be ef-
memories), and such characteristics have been shown to fective to decrease BPSD in the studied population. We rec-
help people relax and improve their moods (Aşiret & ommend that health care providers utilize person-centered
Kapucu, 2016; Chu et al., 2014). These cited studies con- care as an essential part of the treatment when trying to
firm our results that show significant effects for these two reduce the BPSD and rehabilitate the cognitive function of
types of therapy. Conversely, cognitive therapy might persons living with dementia. Specifically, given that remi-
not focus on the mood or feelings of persons living with niscence therapy was effective on both BPSD and cognitive
e262 The Gerontologist, 2022, Vol. 62, No. 4

function and that its effect size was superior to that of dementia: A three year longitudinal study. Journal of Alzheimer’s
other interventions (i.e., cognitive and music therapy and Disease, 40(1), 221–226. doi:10.3233/JAD-131850
multisensory stimulation), we suggest this type of therapy Chenoweth, L., Stein-Parbury, J., Lapkin, S., Wang, A., Liu, Z.,
as the first choice of nonpharmacological intervention that & Williams, A. (2019). Effects of person-centered care at the
should be applied to manage BPSD and maintain the cogni- organisational-level for people with dementia. A systematic
tive function of our population of interest. review. PLoS ONE, 14(2), e0212686. doi:10.1371/journal.
pone.0212686
Chu, H., Yang, C. Y., Lin, Y., Ou, K. L., Lee, T. Y., O’Brien, A. P.,
& Chou, K. R. (2014). The impact of group music therapy on
Supplementary Material depression and cognition in elderly persons with dementia:
Supplementary data are available at The Gerontologist online. A randomized controlled study. Biological Research for Nursing,
16(2), 209–217. doi:10.1177/1099800413485410
Clare, L., Linden, D. E., Woods, R. T., Whitaker, R., Evans, S. J.,
Parkinson, C. H., van Paasschen, J., Nelis, S. M., Hoare, Z.,
Funding Yuen, K. S., & Rugg, M. D. (2010). Goal-oriented cognitive
This work was supported by the Ministry of Education through the rehabilitation for people with early-stage Alzheimer disease:
Basic Science Research Program of the National Research Foundation A single-blind randomized controlled trial of clinical efficacy.
of Korea (grant number NRF-2020R1A6A1A03041989). The American Journal of Geriatric Psychiatry, 18(10), 928–939.
doi:10.1097/JGP.0b013e3181d5792a
Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1),
155–159. doi:10.1037//0033-2909.112.1.155
Conflict of Interest Cohen, J. (2013). Statistical power analysis for the behavioral sci-
None declared. ences. Academic Press.
DerSimonian, R., & Laird, N. (1986). Meta-analysis in clin-
ical trials. Controlled Clinical Trials, 7(3), 177–188.
doi:10.1016/0197-2456(86)90046-2
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