Review of
Nonpharmacological Interventions for Agitation and Other BPSDs
​
In the United Kingdom in 2017, a review of existing studies for nondrug interventions and their effectiveness in addressing agitation in dementia was published in the Translational Psychiatry journal (Ijapo EO, 2017). The author reviewed the results of a computer search spanning 12 years of studies from scholarly websites such as PubMed , MEDLINE, and PsychInfo, to name a few: some studies were reviews themselves of interventions targeted to reduce agitation in dementia.
Before summarizing the results obtained, it is important to note the differences in the definition of agitation. For this review of the literature, the researchers defined agitation per the author as “restless behavior, or improper physical or verbal actions that may cause trouble for family members, caregivers and other service users” (Ijapo, 2017). In a 2003 article conducted by a team of physicians and nurses at the Geriatric Research, Education and Clinical Center of the E.N. Rogers Memorial Veterans Hospital in Massachusetts, the definition of resistiveness to care sounds much like the definition for agitation. In the article “resistiveness to care occurs when an individual with dementia interferes with a caregiver attempting to provide care. Resistiveness to care is defined as the repertoire of behaviors with which persons with dementia withstand or oppose the efforts of a caregiver and can be measured by a direct observation during care”.
There are many definitions of agitation in the dementia literature, and the definition drives the results of the studies and its interpretation. To reduce the discrepancy and better define what behaviors are actually targeted in clinical studies of the effects of treatment, the International Psychogeriatric Association stepped in to help. As result of its Agitation Definition Working Group (ADWG), experts in 2015 defined agitation in patients with cognitive disorders as:
“i) occurring in patients with a cognitive impairment or dementia syndrome,
ii) exhibiting behavior consistent with emotional distress,
iii) manifesting excessive motor activity, verbal aggression, or physical aggression, and
iv) evidencing behaviors severe enough to cause excess disability and not solely
attributable to another disorder (psychiatric, medical, or substance-related) or a
suboptimal care condition” (Cummings et al, 2015).
A concise definition that can be applied across disciplines will be extremely useful in future research of pharmacological and nonpharmacological studies alike.
The definition of therapies in this study is loosely defined at best and might better be called interventions. The multisensory stimulation studies involved therapeutic touch, acupressure, massage, and multisensory exposure*. One of these studies, which combined interventions of therapeutic touch and acupressure with Montessori activities decreased agitation (Lin et al, 2009).
Another multisensory study using music in addition to massage, therapeutic touch, and multisensory stimulation decreased mild agitation immediately but had no long-term effects and did not reduce severe agitation (Livingston et al, 2014). Tailored activities training to caregivers/families reduced agitation, improved dementia skills, and decreased caregiver burden (Gitlin et al, 2008). Training caregivers in person-centered skills and communication techniques showed an immediate decrease in severe agitation with effects lasting up to 6 months. It is assumed that individual attention might be a factor in this approach’s success, as well as empowering the caregivers to feel more competent in their skills (Livingston et al, 2014).
*Other multisensory studies involve providing different types of stimulation such as flexible lights, smell, sound, texture, and or moving or vibrating cushions or pads.
Aromatherapy studies, particularly with the use of lavender oil versus control oil, showed no evidence of reducing agitation (O’Connor et al, 2013).
Aroma-acupressure, however, had a better effect than aromatherapy in isolation (Yang et al, 2015).
In a study involving 30-60 minutes of bright light exposure, called light therapy, no benefit was found in reducing agitation (Livingston et al, 2014).
Music therapy results are quite different. In a study using music familiar to the patient, a significant decrease in agitation and other BPSD were found (Raglio et al, 2008 and Sung et al, 2005)
In another study, Abraha et al (2017) conducted an overview of 38 systematic reviews and more than 140 studies of non-pharmacological interventions including sensory stimulation, exercise, pet therapy, music, dance, light therapy, and massage among other approaches. It was found that music therapy was the only non-pharmacological sensory intervention that reduced agitation. Other studies show effects may be short-term (Vink et al, 2013), but there is a positive effect, nonetheless.
Other therapies and techniques including animal assisted/pet therapy, behavior management techniques, physical exercise, and simulated presence therapy (video or audio recordings of loved ones) all show inadequate evidence for efficacy in treating behavioral symptoms (Abraha et al, 2017).
Activity therapy, which can include dance, sports, and drama, is a broad category that some studies have shown can provide a reduction in falls, better sleep (King et al, 1997), and improved mood and confidence (Young & Dinan, 1994). One approach to dance therapy, known as ‘jabadeo’ involved participants moving interactively with others with no prescribed steps or motions (Perrin, 1998). Perrin reported that many people found this non-sexual physical contact soothing.
In the early stages of dementia, CBT, or Cognitive Behavioral Training, has shown some effectiveness. When modified for dementia clients, CBT usually involves an individualized approach of implemented meaningful activities and memory aids with a goal of decreasing depression and increasing quality of life. In one Norwegian descriptive case study, two clients with early-stage AD experienced 11 weeks of CBT. Due to the disease, one client did not have the insight or the motivation to participate in the study and did not understand the purpose of the intervention. He did, however, benefit from looking at photo albums, and felt by attending the meetings that he was contributing. The second client, however, benefitted from the use of weekly and daily planners as it helped her keep track of time and notice what activities were most meaningful to her (in this case, light housework) and had a positive effect on her mood (Staubo et al, 2017).
In a recent CBT study that focused on 50 mild AD clients and their caregivers, 25 weekly or bi-weekly structured sessions were provided that produced a significant reduction in depression, apathy, and improved the quality of relationship to the caregiver. Other BPSD, however, were unaffected (Forstmeier et al 2017). The study consisted of various techniques that allowed for an individualized approach when warranted. The following session components were utilized:
-
Diagnosis and goal setting – analysis of presenting behaviors and issues, emotions, and setting goals for sessions.
-
Psychoeducation – information regarding AD and its causes, course, and treatment options.
-
Engagement in pleasant activities – adopting a weekly schedule and increasing engagement in pleasant activities (social, physical, leisure).
-
Cognitive restructuring – dysfunctional thoughts (related to depression, anxiety, or anger) are recorded and evaluated, and more helpful thoughts practiced.
-
Life review – reminiscence through life’s phases with photos, music, memorabilia to support.
-
Training caregiver in behavior management techniques – ABC (antecedent, behavior, consequence) identification and application.
-
Interventions for the caregiver – care of self, anger management, social support; these may be presented in sessions without the patient present.
-
Couples counseling – sessions focusing on expressing fears, new roles, improving communication, joint coping, future planning, etc. (Forstmeier et al, 2015).
The rationale for believing CBT is suitable for dementia stems from the fact that many of the challenges posed by dementia are related to the IWD’s thinking style (James, 2001). James explains that cognitive misinterpretations, biases, distortions, communication difficulties, and erroneous problem-solving strategies all stem from these thought processes.
One other therapy mentioned in Ijapo’s 2017 review of the literature is ECT (electroconvulsive therapy). The 23 study participants had behavioral disturbances that were not responsive to drug or nonpharmacological interventions. Each subject received a dozen treatments of ECT, which significantly reduced their use of antipsychotics during the treatment period (Acharya et al, 2015). ECT is only used with the most severe BPSD (usually physical aggression or self-harm) that do not respond to pharmacological treatment. Long term effects of the use of ECT in dementia remain unknown.
Finally, addressing unmet needs was effective in reducing agitation (Cohen-Mansfield et al, 2012 and Jakobson et al, 2015). It seems odd that this would be included in a study of interventions for agitation as it is unbelievably obvious!! The unmet need would have to be identified, however, to be addressed. Lack of effective communication with an IWD can be a detriment to resolving issues causing agitation and discomfort in the first place. In 2000, Cohen-Mansfield developed a model that divided these unmet needs into three functions of behaviors. The first group included behaviors resulting from the client attempting to meet or obtain a need. The second function included behaviors resulting from an attempt to communicate a need, and the third function would be behaviors that result from an unmet need (Cohen-Mansfield, 2000). Cohen-Mansfield’s model could assist caregivers in pursuing the causes of behavior and how to address the client’s issues. Douglas et al (2004) gave examples of each of these functions in a summary of interventions. In order, the examples include pacing to provide stimulation (attempting to meet a need), repetitive questioning (attempting to communicate a need), and aggression resulting from (an unmet need of) pain or discomfort.
Behavior Management, although not addressed in the Ijapo (2017) study, is based upon the ABC (antecedent, behaviors, and consequences) model. This person-centered approach identifies the precursor or antecedent (what happens prior to) a behavior and identifies the consequences that result from the behavior. The intervention is then chosen based on the “individual’s preferences; changing context in which the behavior takes place; and using reinforcement strategies and schedules that reduce the behavior” (Douglas et al, 2004 p. 172). This approach has reduced some stereotypical behaviors of wandering. Results vary according to individual responses to the triggers causing the behavioral issue in the first place.
Another form of non-pharmacological treatment of behavioral issues in dementia is reality orientation. This intervention is intended to help the IWD orient in their environment using signs, notices, and other memory aids, and was originally developed for use with PTSD. Study results are conflicting as to its efficacy. Some have found an initial lowering of mood when using such aids, allegedly due to reminding the client of the progression of their disease (Goudie & Stokes, 1989 and Baines et al, 1987). However, in 2001, Spector et al (2002a) reviewed six randomized-controlled trials of reality orientation and reported positive findings in improved cognition and behavioral symptoms. It is not clear if such effects are lasting, however.
Validation therapy has observed a resurgence in interest in the dementia community despite few empirical studies and a lack of proven efficacy. Validation therapy was developed by Naomi Feil and involves an emphasis on the client’s feelings and emotions. It is an attempt to decipher the meaning behind behaviors and emotions that are often obscured by unclear speech or seemingly unrelated behavior. Feil believes the IWD retreats into their inner reality based on personal feelings rather than the present reality, which they may find too painful (Douglas et al, 2004). The client’s emotions are reflected in the response of the caregiver and therefore validated and confirmed.
Reminiscence therapy can be conducted individually as a group and involves art, music, photos, etc. that help the patient relive past positive events or experiences. According to Douglas (2004), few high-quality controlled studies have addressed this approach. Reminiscence therapy’s premise is to increase well-being, improve social interaction, and provide relaxation and cognitive stimulation. Most persons with dementia can gain pleasure from listening to music from their past and/or reviewing a photo album from their own life history.
Art therapy can provide an opportunity for self-expression when it allows content and color choice. Killick & Allan (1999) reported improved social interaction and self-esteem with art therapy.
Although many studies have reported benefits of these strategies, more valid and reliable research needs to be conducted so results can be replicated and implemented. Studies may lack a clear outline of how interventions were conducted including staff training, interaction style, and communication techniques. Missing, too, is an absence of measured personality characteristics of the dementia patient prior to treatment and its effect on results. There are also few well-conducted studies discussing the caregiver’s interpersonal characteristics and how learning style, attitude, feelings of role captivity, etc. impact the care of the patient. One other observation worth noting—it seemed the studies (and their authors) spend more time on how to measure, define, and assess behavioral issues than how to address them. Herein lies the key to BPSD or NPS—whatever we want to call them – in dementia.
Sources:
Abraha I, Rimland JM, Lozano-Montoya I, Dell’Aquilla G, Velez-Diaz-Pallares M, Trotta FM et al. Simulated presence therapy for dementia. Cochrane Datab Syst Rev, 2017; 4:Cd011882.
Abraha I, Rimland JM, Trotta FM, Dell’Aguila G, Cherubini A, Cruz-Jentoft A. et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older persons with dementia. The SENATOR-OnTop series. BMJ Open, 2017;7:e012759.
Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ et al. Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. Int J Geriatr Psychiatry, 2015;30:256-273.
Baines S, Saxby P, Ehlert K. Reality orientation and reminiscence therapy: a controlled cross-over study of elderly confused people. British Journal of Psychiatry, 1987;151:222-231.
Cohen-Mansfield J, Jensen B, Resnick B, Norris M. Knowledge of and attitudes toward nonpharmacological interventions for treatment of behavioral symptoms associated with dementia: a comparison of physicians, psychologists, and music practitioners. Gerontologist, 2012;52:34-45.
Cummings J, Mintzer J, Brodarty H. Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition. Int Psychogeriatr, 2015;27:7-17.
Douglas S, James I, Ballard C. Non-pharmacological interventions in dementia. Adv Psychiatr Treat, 2004;10:171-177.
Forstmeier S, Maercker A, Savaskan E, Roth T. Cognitive behavioural treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial, Crossmark Study Protocal, 2015;16:526 DOI 10.1186/s13063-015-1043-0.
Forstmeier S, Maercker A, Savaskan E, Roth, T. Integrative cognitive behavior therapy for people with mild Alzheimer’s disease: results of an RCT. Innovation in Aging, 2017;1:344-344.
Gitlin LN, Winter L, Burke J, Chernett N, Dennis MP, Hauck WW. Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study. Am J Geriatr Psychiatry; 2008;16:229-239.
Goudie F & Stokes G. Understanding confusion. Nursing Times, 1989;85:35-37.
Ijaopo EO. Dementia-related agitation: a review of non-pharmacological interventions and analysis of risks and benefits of pharmacotherapy. Transl Psychiatry. 2017;7(10):e1250. Published 2017 Oct 31. doi:10.1038/tp.2017.199
Jakobson E, Avari J, Kalayman B. Non-pharmacologic interventions for treatment of agitation in dementia in nursing home residents. Am J Geriatr Psychiatry, 2015;23(3 Suppl. 1):S139-S140.
James I. Psychological therapies and approaches in dementia. In Dementia: Management of Behavioural and Psychological Symptoms [eds. C. G. Ballard, J. O’Brien, I. James, et al]. Oxford: Oxford University Press, 2001
Killick J & Allan K. The arts in dementia care: tapping a rich resource. Journal of Dementia Care, 1999; 7:35-38
King A, Oman R, Brassington G, et al. Moderate intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. JAMA, 1997;277:32-37.
Lin, LC, Yang MH, Kao CC, Wu SC, Tang SH, Lin JG. Using acupressure and Montessori-based activities to decrease agitation for residents with dementia: a cross-over trial. J Am Geriatr Soc 2009; 57:1022-1029.
Livingston G, Kelly L, Lewis-Holmes E, Baio G, Morris S, Patel N et al. Nonpharmacological interventions for agitation in dementia: systematic review of randomized controlled trials. Br J Psychiatry 2014;205:436-442.
O’Connor DW, Eppingstall B, Taffe J, van der Ploeg ES. A randomized, controlled cross-over trial of dermally-applied lavender (Lavandula angustifolia) oil as a treatment of agitated behavior in dementia. BMC Complement Altern Med, 2013;13:315.
Perrin T. Lifted into a world of rhythm and melody. Journal of Dementia Care, 1998;6:22-24.
Spector A, Orrell M, Davies S, et al. Reality orientation for dementia. Cochrane Library, 2002a; issue 3. Oxford: Update Software.
Staubo H, Misvaer N, Bjornstad Tonga, J, Kvigne K, Ulstein, I. People with dementia may benefit from adapted cognitive behavioural therapy. Norweigian Journal of Clinical Nursing/ Sykepleien 63874; Forksning 10.4220, Dec. 2017.
Vink AC, Slaets JPJ, Zuidersma M, De Jonge P, Boersma F, Zuidema SU. The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: a randomized controlled trial. Int J Geriatr Psychiatry, 2013; 28:1031-1038.
Yang MH, Lin LC, Wu SC, Chiu JH, Wang PN, Lin JG. Comparison of the efficacy of aroma-acupressure and aromatherapy for the treatment of dementia-associated agitation. BMC Complement Altern Med, 2015;15:93.
Young A & Dinan S. ABC of sports medicine. Fitness for older people. BMJ, 1994;309:331-334.
'm a paragraph. Click here to add your own text and edit me. It's easy.