INVITED COMMENTARY ON: Non-pharmacological interventions in dementia

The various therapies described have a range of therapeuticgoals, not always explicitly stated by those responsible fortheir development. Reality orientation, for example, has hada clear focus on cognition, particularly orientation. Afterfalling from favour, largely through insensitive application,it has recently been adapted and revived as ‘cognitivestimulation’ (Woods, 2002). In a recent trial, the changesin cognitive function were of the same order of magnitude asthose reported in trials of acetylcholinesterase inhibitors(Spector et al, 2003). In its new form, it is associated withimprovements in quality of life, but there is no suggestionthat it would, or should, affect BPSD. Reminiscence work hashad a variety of aims, plausibly spanning both cognition (autobiographicalmemory) and mood. Validation therapy, with its emphasis on theemotional content of communication, similarly should have itsmain impact on affect. The ‘alternative’ therapiesalso have a range of potential aims, although the putative impactof aromatherapy and music therapy on arousal levels is of particularinterest, if this is seen as a possible factor in behavioursdescribed as agitated.

Need for recognition of anxiety and depression as key challenges in dementia care

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Need for recognition of...

The authors’ comments on brief psychotherapies serve asa reminder of the importance of responding more actively tothe well-documented high levels of anxiety and depression symptomsshown by people with dementia (Ballard et al, 1996a,b). It isan obvious step to apply well-established psychological therapiessuch as cognitive–behavioural therapy for depression (Scholey & Woods, 2003)and relaxation for anxiety (Suhr et al, 1999)to people in the early stages of dementia who display such symptoms;there is now no doubt regarding the feasibility of such an approach,and one study successfully utilised family carers as therapists(Teri et al, 1997). More challenging are those people with severedementia who have comorbid anxiety and depression; this is wheresome of the alternative therapies and activities may have mostto contribute.

BPSD v. challenging behaviour?

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BPSD v. challenging behaviour?

The difference in terminology noted by Douglas et al reflectsa fundamental difference in conceptualisation, which, if notaddressed, could stifle the development of effective non-pharmacologicalapproaches. In general, clinical psychologists prefer (althoughthey are not completely happy with this) to talk of behaviourthat challenges, because of its implicit reminder that the problemlies in part with our reaction to the behaviour, which of itselfmay not present a problem to the person with dementia. Challengingbehaviour is a function of a particular care environment; ina different care setting, the behaviour in question may notbe elicited, or may not be viewed as a problem by those providingcare. The association between carer strain and difficult behaviouris often noted, but rarely is the possibility entertained thata stressed carer behaves in ways that elicit more difficultbehaviour from the person with dementia (Woods, 2001). The implicationis a difficult one; rather than prescribing a ‘therapy’,alternative or otherwise, some of our interventions have toinvolve changes in the attributions, attitudes and interactionsof family carers and paid care-workers. It is here, indeed,that a fuller understanding of the carer’s cognitionsand affect regarding the person in their care, and also of theirbehaviour in relation to other members of the care system, willprove invaluable.

Need for individualised formulations

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Need for individualised...

Having identified symptoms such as agitation, aggression, wanderingand the like, it is tempting to identify the most effectivetherapeutic approach for each. However, the same label may becomeattached to quite different behaviours, requiring quite differentinterventions. Add to this the person’s unique socialenvironment, their particular profile of physical health, theirlife history and so on, and it is clear that an individual assessmentand analysis of each person’s situation is needed. Evenif two people with dementia are both thought to be showing agitationbecause of a high level of internal arousal, what helps onemay be quite different from what helps the other. One person’srelaxing and calming hand-massage may be another person’sinvasion of personal space and confinement (Brooker et al, 1997).Evidence-based practice in dementia care entails establishing‘what works for whom’, rather than a standard approach;this may require readiness to adopt a more empirical approach,using simple single-case designs, with the person as their owncontrol.

Implementing change

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Implementing change

If it is indeed the case that effective non-pharmacologicalinterventions must be based on individual assessment and formulation,with an understanding of the role of the social environmentin the development and maintenance of the problem, trainingalone, for family carers or for care-workers, will be of limiteduse. Input is also required from mental health professionals(including community mental health nurses and clinical psychologists,as well as psychiatrists) who have skills in dementia care andthe ability to work at a systemic level. Some models of howthis might be achieved are already being developed, for examplethrough regular visits to a care home by a mental health nurse(Proctor et al, 1999; Ballard et al, 2002) or through the inputof a multidisciplinary team in a family care context (Hinchliffe et al, 1995).Further analysis, development and evaluation ofthese intervention models is required, if non-pharmacologicalinterventions are to take their proper place in the real worldof dementia care.

References

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