VANCOUVER, B.C. – Nonpharmacologic interventions bestow clinically meaningful benefits on patients with dementia, a literature review has concluded.
But these aren’t one-size-fits-all activities, Dr. Clive Ballard said at the Alzheimer’s Association International Conference. Different activities improve different problems, leading to the possibility of targeted treatment.
"Reminiscence improves depression but no other neuropsychiatric symptom. Social interaction and pleasant activities improve agitation but not mood," said Dr. Ballard, a professor of age-related diseases at King’s College London. "There is a substantial amount of data emerging that shows not only that these interventions are helpful, but that we can target them to specific symptoms."
Nonpharmacologic interventions have several benefits for patients who are living in an institutional setting: They produce results, they don’t come with the baggage of physical side effects, and – perhaps most importantly – they are simple.
"If you’re going to do something in a nursing home, it has to be easy and practical. If it’s not simple, you can’t implement it."
Dr. Ballard and his colleagues reviewed 56 studies of nondrug interventions designed to improve dementia care in nursing homes; 32 of these have been published since 2008, which he said is "very encouraging."
The studies varied widely in duration, from 1 to 24 weeks. The investigators grouped the interventions into broad categories: social interaction, exercise, personalized care, and person-centered care.
Twelve studies addressed the use of reminiscence. The studies included groups of up to 130 residents, and ran for a median of 7 weeks. "The results were encouraging, and the most consistent outcome was for depression," with the majority of residents showing a significant improvement in that measure, Dr. Ballard said.
"There is increasing controversy about the benefit of antidepressants in the context of dementia, so it’s especially encouraging that there are nondrug interventions" for depression, he said.
Five trials looked at engaging residents in pleasant activities; the median length of intervention was 3.5 weeks. "All four of the trials that looked at agitation as an outcome showed a significant benefit," Dr. Ballard said. "There was less clear-cut evidence of an effect in depression. One trial also reported an improvement in apathy."
Seven studies examined the benefits of exercise; the median study length was 16 weeks. "There was some evidence of improvement in depression, but it was marginal, with two showing a benefit and three not. None of the trials showed that any other neuropsychiatric condition improved." Residents who exercised did, however, show improvements in gait and mobility.
There were 10 studies on personalized music. The results were "not quite as consistent" as those of studies in which patients engaged in pleasant activities, but four of the seven that looked at agitation showed a significant benefit. There wasn’t any benefit for depression. "This one is a really simple thing to do – it can be used as a reminiscence tool or simply having someone sitting with patients and listening together to music the patient likes."
Two trials examined "person-centered care" – care that is individually tailored to the patient’s preferences and goals. These studies compared person-centered care to care as usual. One was a 4-month study of almost 300 patients. There were significant improvements in agitation, but no reduction in antipsychotic use. "The effect on quality of life was marginal," Dr. Ballard said.
The second was a 10-month intervention comparing six facilities that incorporated person-centered care and six having usual care. "These showed a halving in the use of antipsychotic drugs, with no worsening of symptoms. But neither was there an overall improvement in behavior," he said.
However, 42 patients in the active group, who were on antipsychotic drugs at baseline, showed significantly less social withdrawal as the study progressed, Dr. Ballard said. "Their social interaction, activity, and overall well-being significantly increased. It appeared that stopping the antipsychotics led to an improvement in their quality of life, but there was probably not a lot of improvement in those who were not on antipsychotics to start with."
It’s hard to tell why the programs improve behavior and well-being, but Dr. Ballard said one sad fact may hold an answer.
"We have done two studies of dementia care mapping, which involved about 1,000 patients in 30 homes. The residents were observed every 5 minutes over 6 hours of waking time, to ascertain the amount of time spent in social interactions with other residents or staff. It was a total of about 2 minutes. If someone’s life consists of sitting alone all day, with only 2 minutes of interacting with another human, no drug is going to sort that out."