NCBI Bookshelf. There are a number of possible ways to group and categorise interventions in dementia care, for example, by the type of treatment approach used. In this and the following chapter, the main grouping is by the therapeutic goal, with three major domains highlighted: the maintenance of function, including cognitive functions, the management of behaviours that challenge and the reduction of comorbid emotional disorders.
Each of these three areas has the aim of improving the quality of life and well-being of the person with dementia, which may in turn impact on the well-being of those providing care.
In this chapter, we look at the evidence for the effectiveness of interventions designed to enhance and increase functioning; in the following chapter, the aim of therapy is to reduce depression or agitation or to modify other distressing symptoms of dementia — although potentially this may also be achieved by improving function in other areas. This chapter focuses specifically on outcomes for the person with dementia, whilst in Chapter 9 interventions directed at carers, whose experience of the effects of dementia is often equally important, are discussed in detail.
However, with regard to the intervention reviewed in this chapter, where relevant effects on carers have been documented, these will be highlighted here. Cognitive symptoms are, of course, recognised as the core of any definition of dementia, and interventions targeting them have been the subject of much research and interest. However, the link between improving cognitive symptoms and maintaining day-to-day function is also key.
In considering the efficacy of interventions in this chapter, it is this broader effect that must be the eventual goal. This chapter includes discussion of both pharmacological and non-pharmacological approaches. Evaluating the effects of such different types of interventions alongside each other is a relatively new endeavour and some caution is required, especially when the double-blind RCT is taken as the gold standard Woods, In particular:.
Although some interventions can be offered for a discrete period of time, such as half an hour per day, many others involve intervention at the level of the care setting or in the general approach or interactive style of those providing care. Cluster randomised designs would be appropriate for evaluating interventions at care-setting level, but require considerable resources. Where the intervention is designed to be delivered through carer interaction, a key step is to ensure that any training provided is effective in producing the required type and quality of interactions.
Promoting independence is important at all stages of dementia and is used in this guideline to mean facilitating performance of or engagement in as much activity as is reasonable and tolerable for the individual. Though the level of independence will change with the stage of dementia and other illnesses, a balance across personal care and productive, leisure, social and spiritual activities is important for quality of life and well-being.
As function deteriorates, it is not uncommon for people with dementia to withdraw from more complex activity and social environments and for others to want to perform tasks for them. However, the literature suggests that functioning in activities of daily living often deteriorates below what would be expected by the illness alone Tappen, ; Beck et al.
Therefore the person with dementia, care providers, family and friends should consider opportunities to maintain an active life and social roles and to promote independence beginning in the early stages of the condition. When exploring appropriate activities, it is also important to consider the right level of stimulation and challenge for the individual.
The complexity of activity and level of engagement will change; however, it should not be assumed that the person with dementia does not retain abilities to perform an activity. Social networks, voluntary services, communities, and health and social services can play an important role in socially including people and maximising independence at all stages of illness. There is little research from which to draw clear conclusions on specific interventions for promoting independence.
The following is, therefore, a summary of good practice. Interventions should be selected and implemented based on the needs and strengths of the individual. It is important to note that any one person may benefit from any combination of strategies listed below.
Further information about each of the primary-level studies referenced below can be found in Appendix 15b. People with dementia also need to have their vision and hearing tested and the most appropriate aid available for use when interacting Oddy, Trying out different phrases and words to find the ones that elicit the best response and adapting tone and rate of speech can make the difference between the person with dementia performing a task with a verbal prompt and the care giver carrying out the task for the person.
As well as using verbal and body language, communication may need to take written or pictorial form Oddy, , such as memory books. Where a person with dementia has a specific communication problem, individualised advice regarding appropriate strategies will be needed from a speech and language therapist.
Literature and current practice suggest that for people with dementia activities of daily living ADL skill training can promote independence in personal care tasks for example, dressing, feeding and washing and maximise the use of skills and participation in their own care.
The training can also lead to less disruption during ADL performance and reduce carer stress Tappen, ; Beck et al. However, more research is required. The intervention may involve analysing the results of the assessment to develop individualised programmes for enabling people to perform as many of their ADL tasks as possible themselves Tappen, ; Beck et al.
The programmes include graded assistance, which means the care giver providing the least amount of assistance needed at each step to complete the task. Strategies may include verbal or visual cues, demonstration, physical guidance, partial physical assistance and problem solving Beck et al. The principles of ADL skill training can be applied across various activities beyond personal care.
Care providers and the person with dementia should also consider preferences, interests and life histories in order to create meaningful activity plans Kolanowski et al. This involved individualised assessment, working with individuals to identify types of occupation and activity that were most likely to lead to well-being and a programme of activity that was rich, integrated with the local community, flexible and practical.
Management and staff training issues also needed to be addressed. The function of this technology is wide ranging, with many products and systems currently available through commercial suppliers or social services. It is not within the scope of this guideline to evaluate or recommend any one piece of assistive technology, but to consider the technology more broadly as an intervention for people with dementia. Adaptive aids and environmental modifications to promote safety and independence in performing a broad range of ADLs are in common use.
Adaptive aids can range from memory aids to bathing equipment and are aimed at minimising the impact of physical, cognitive and sensory deficits. Similarly, low-level technology for example, lights attached to a movement sensor is widely used in adaptive aids to minimise risk without the need for action by the user. Low-level technology can stand alone without the need for sophisticated computer and telecommunications systems Cash, Environmental modifications can be as simple as visual prompts and signs or as complex as structural changes to the home, such as shower installations.
Information for the purpose and proper use of adaptive aids should be provided. However, some clinicians find combining memory aids with memory training exercises such as spaced retrieval or cueing hierarchy can improve the independent use of the aids and also benefit people into the moderate stages of dementia Bourgeois et al.
Memory aids need to be introduced in collaboration with the user to find the most appropriate aid for him or her and consideration given to how the user can best utilise the aid. An intervention may not work at first or in isolation, so it is useful to think about the whole person in his or her environment before stopping it. For example, Dooley and Hinojosa note that combining adaptive aids with carer education and environmental modifications contributed to improved outcomes in independence for people with dementia and reduced stress for their carers.
People with dementia may be able to live safely and independently, minimising potential risks Department of Health, a. A telecare package may involve monitoring activity patterns to detect any changes that may warn of potential health changes or of an event such as a fall Magnusson et al.
Responsive alarms can detect risks by monitoring motion for example falls and the presence of fire and gas and triggering a warning to a response centre or carer Department of Health, a. The significant benefit of telecare for a person with dementia is that many devices are passive so the individual does not need to remember where they are or how to use them Cash, Telecare is one intervention that can be implemented alongside but not replacing care provision Department of Health, a.
Guidance suggests that benefits can be gained by keeping people with dementia at the centre of the development and application of technology taking into account ethical considerations and involving them in a partnership working with services and care providers Cash, ; Magnusson et al. Initial findings support the use of assistive technology in aiding people to stay in the community longer, thereby delaying moves to higher dependency care Cash, , but further research is needed before any firm conclusions can be drawn Magnusson et al.
The Department of Health has published a few useful guides for establishing telecare in local communities for example, Department of Health, a. Although conclusions cannot be drawn from current research on the benefits of a specific exercise programme, it is widely accepted that exercise is important for the health of people with dementia Oddy, Many benefits are stated to occur — ranging from improved continence to slowing loss of mobility and improving or slowing loss in strength, balance and endurance levels — with overall improved physical functioning in comparison with people not receiving exercise Oddy, ; Schnelle et al , ; Shimada et al.
Exercise is also widely used in preventing falls see NICE, b. The literature is wide and varied, with descriptions of both standardised group and individualised exercise programmes, which are widely used in practice.
Such programmes may involve walking, gait training, resistance training or strengthening exercises, balance and endurance training Tappen et al. Some reports recommend the use of walking and conversation simultaneously to improve compliance to the exercise Tappen et al. Combining exercise with other interventions, such as continence care Schnelle et al. Teaching care providers effective strategies to encourage exercise and avoid behavioural problems associated with increased activity may make exercise training most effective Teri et al.
Risk should not necessarily represent a barrier to people with dementia receiving opportunities for exercise. The Department of Health and independent bodies report that people with dementia are often excluded from rehabilitation programmes because of the nature of the condition Department of Health, ; The Nuffield Institute, However, there is evidence that they can benefit equally well from rehabilitation-based services, particularly community services Department of Health, ; Nuffield Institute, Promoting and maintaining cognitive skills and mobility and independence in wider ADLs is possible Oddy, ; Beck et al.
This process is no different for people with dementia, although programmes may need to be adapted to compensate for cognitive, perceptual or mood elements. In addition, tailoring programmes to meet the needs of the individual may require time, adaptive aids, communication strategies and organising staff in a different way Department of Health, Many of the interventions described in this chapter can be used in a rehabilitation programme.
Support in considering the balance of risks and benefits in these instances can be helpful. One intervention is often not enough because people with dementia do not only experience cognitive impairment, but often physical, emotional and social concerns as well. By combining interventions, care providers and professionals are more likely to succeed in promoting the independence of an individual than with the use of one intervention alone Gitlin et al.
Physical health difficulties may contribute to loss of independence, and it is essential that such difficulties are assessed and treated appropriately. Collaborative working between psychiatry and geriatric medicine as part of a multidisciplinary approach would help to achieve this. Toileting is often an important issue. There are often treatable causes that can be uncovered by medical investigation.
Observation of the situation is essential to determine the right strategies to maximise independence in toileting. Specialist advice can also be obtained through nursing services, and many communities have specialist continence advisors. The following strategies may be combined:. Two sources of qualitative evidence on the experiences of people with dementia and their carers of strategies for promoting the independence of people with dementia met the eligibility criteria set by the GDG : a non-experimental study with evidence from professionals, carers and people with learning disabilities and dementia Stalker et al.
A study involving people with learning disabilities and dementia, along with their key worker and relatives, that explored how far people with learning disabilities and dementia were involved in making decisions and choices in their own lives found wide variations Stalker et al. The findings indicate that staff training and development is needed to ensure that care environments enable people with dementia and learning disabilities to exercise choice and control over their everyday lives, and so maximise their independence.
Ultimately, promoting independence with someone or for oneself is dependent upon opportunities for doing so. By finding out about the person through spending time with him or her, asking family and friends and conducting holistic assessments and observations to keep information current, services and care providers can continually shape interventions to maximise independence.
By including the person with dementia and using information from a variety of sources, staff can devise and use a variety of techniques to promote independence in a meaningful way. Promotion of independence means the involvement of the person in his or her ADLs, communities and care, treating him or her with respect, preserving dignity and looking for the abilities and strengths within the person.
Qualitative evidence on the experience of people with dementia and carers points to the contribution that assistive technology can make by reducing risks and promoting independence. Other qualitative evidence highlights the importance of promoting independence for people with dementia and learning difficulties, who should have the opportunity to exercise choice and control over their everyday lives.
Rigorous evaluations of non-pharmacological interventions are at an early stage of development, in relation to the maintenance of cognitive function. The creativity and enthusiasm of practitioners in the field has often not been followed up by systematic assessment of outcomes, and so a section such as this, which aims to draw together the evidence base, cannot do justice to the range and diversity of interventions that have been developed.
These are:. Particularly in relation to cognitive rehabilitation approaches, there is a strong tradition of evaluation through series of single case studies, using experimental designs. Multi-sensory stimulation is most typically used with people with moderate to severe dementia, whereas the other approaches are more appropriate for mild to moderate dementia.
Reminiscence work is probably the most commonly used of these approaches in the UK. Current projects emphasise the importance of a person-centred approach as a basis for any of these interventions. The main emphasis here is on cognitive change, with reference to ADLs and quality of life as an important context for the clinical significance of any changes in cognition. In Chapter 8 , other outcomes are considered for these approaches. We conducted a new systematic search for RCTs that assessed the efficacy of the specified psychological interventions for people with dementia see Table 8.
Study information table for trials of psychological interventions in people with dementia. Nineteen trials met the guideline eligibility criteria, providing data on 1, participants.
In addition, 39 studies were excluded from the analysis further information about both included and excluded studies can be found in Appendix 15c. Evidence from critical outcomes and overall quality of evidence are presented in Table 9.
The full evidence profiles and associated forest plots can be found in Appendix 16 and Appendix 20 , respectively. However, the results do not provide any evidence that cognitive rehabilitation improves cognition, ADLs or quality of life when compared to an active control mental stimulation.
Summary evidence table for trials of psychological interventions versus control in people with dementia — cognitive symptoms. Of a total of randomised, the mean age was The cognitive-communication stimulation intervention consisted of 8 weekly sessions delivered to groups of six to seven participants by a trainer, followed by monthly contacts with participants on an individual basis.
All participants in the study had been on a stable dose of donepezil for at least 3 months. Of a total of 54 randomised participants, the mean age was All participants in the study had been on rivastigmine for at least 2 months.
Of a total of 13 randomised participants, the mean age was All 13 completed the trial. All participants were taking an acetylcholinesterase inhibitor donepezil. Of a total of 34 randomised participants, the mean age was No significant effects of the intervention were detected on any of the outcome measures of cognitive function.
One economic study was identified that assessed the cost- effectiveness of cognitive stimulation therapy CST Knapp et al. The objective of the study was to investigate the resource implications and cost-effectiveness of CST in care homes and day centres. The economic analysis was conducted alongside an RCT Spector et al. The study adopted the perspective of the health and personal social services.
Costs consisted of those associated with providing the CST intervention, including staff time, travel and equipment, as well as residential care and domestic housing costs, community services costs, and direct medical costs. Clinical outcomes corresponded to those of the study by Spector and colleagues. The primary outcome measure of the analysis was cognition as measured by the MMSE ; quality of life , as measured by the QoL-AD , was a secondary outcome measure.
The time horizon of the analysis was 8 weeks, which is considered a limitation of the study but corresponded with the length of the CST programme. Further analysis was carried out investigating the impact of group size on the cost- effectiveness of CST. The impact of group size on QoL-AD followed a similar pattern. It must be noted that the changes in the ICERs following an increase or reduction in group size were caused by changes in mean weekly costs per person in the CST group exclusively, as effectiveness results were assumed to remain the same regardless of the group size.
However, this may not be true, as clinical outcomes may differ when smaller or larger groups receive the intervention. Subgroup analysis found no difference in results between care homes and day centres. Details of the study are provided in the form of evidence tables in Appendix The evidence suggests that, in the UK, providing cognitive stimulation therapy alongside usual care for people with mild to moderate dementia in both care homes and day-care centres is likely to be more cost effective than usual care alone.
Four sources of qualitative evidence on experiences of people with dementia and their carers of psychosocial interventions for the maintenance of cognitive function met the eligibility criteria set by the GDG : primary research involving six people with dementia, three carers and three care staff Alm et al.
Qualitative evidence on the experiences of people with dementia and their carers supports the potential value of a range of psychosocial approaches aimed at maintaining cognitive function.
An evaluation of a therapeutic programme for people with dementia involving 12 people with dementia six receiving standard care and six receiving the intervention indicates that therapy resulted in a positive effect on friendship Spector et al. Spector and colleagues also report that therapy participants reported enjoying the sessions and wishing that they could continue. Findings from a pilot study of a project to develop a cognitive and communication aid for people with dementia indicate that prompts and stimulation from a computer may assist in reminiscence conversations Alm et al.
People with dementia could enjoy reminiscence when stimulated by a multi-media reminiscence package; they had no difficulty touching the screen and the package maintained their interest —in particular, they liked local and personal pictures. Finally, according to a systematic review of psychosocial interventions for people with milder dementia including evidence from professionals, people with dementia and carers cognitive stimulation reality orientation appears efficacious for people with mild dementia, but the value of other interventions is less clear Bates et al.
There is now reasonable evidence to support the use of cognitive stimulation approaches with people with mild to moderate dementia. Importantly, there are now indications of improvements in quality of life to accompany the well-established modest improvements in cognitive function. The importance of appropriate, respectful, person-centred carer attitudes in the implementation of these approaches has been highlighted in the largest, and most successful, trial to date. Cognitive training has generally not been associated with benefits beyond the particular tasks trained.
There is insufficient evidence to evaluate fully the effects of reminiscence therapy and cognitive rehabilitation in relation to cognitive function in dementia. Donepezil is a reversible inhibitor of acetyl-cholinesterase, galantamine is a reversible inhibitor of acetylcholinesterase and also has nicotinic receptor agonist properties, and rivastigmine is a reversible non-competitive inhibitor of acetylcholinesterases and also inhibits butyrylcholinesterase.
Apart from rivastigmine, no drugs are currently licensed for the symptomatic treatment of people with VaD , DLB , FTD or other dementias subcortical or mixed dementias , although people with these forms of dementia suffer similar problems associated with cognitive symptoms and loss of daily living skills.
If the underlying neurochemical deficit is similar, irrespective of the aetiology of the cognitive impairment, then it is possible that acetylcholinesterase inhibitors or memantine would produce a similar symptomatic effect in other types of dementia. It is therefore important to establish as far as possible from the evidence available whether there is a significant clinical improvement to be gained by treatment with acetylcholinesterase inhibitors or memantine in the other forms of dementia.
The clinical and cost- effectiveness of donepezil, galantamine and rivastigmine for mild to moderately severe AD , and memantine for moderately severe to severe AD are the subject of a NICE technology appraisal 51 and so will not be reviewed here.
The clinical and cost-effectiveness of donepezil, galantamine, rivastigmine, and memantine for PDD are covered in another NICE guideline 52 and so will not be reviewed here. There are no studies of the use of acetylcholinesterase inhibitors or memantine for the treatment of FTD.
A treatment response in VaD is difficult to measure because there is no linear progression of deterioration and a longer period of follow-up is probably required to differentiate between treatment and placebo groups. Studies of MCI are included in this section because of the relatively high rate of progression from the amnestic form of MCI to dementia. Study information table for trials of acetylcholinesterase inhibitors or memantine versus placebo in people with non-Alzheimer dementia.
Ten trials met the guideline eligibility criteria, providing data on 5, participants. Of these, two were unpublished and eight were published in peer-reviewed journals between and In addition, 22 studies were excluded from the analysis further information about both included and excluded studies can be found in Appendix 15d.
Evidence from critical outcomes and overall quality of evidence are presented in Table Or, you can treat them in public areas if no one is available. I hope this post helps you get a beginning grasp on how to successfully work with patients with dementia.
To learn more about dementia and the role of occupational therapy, check out the resources below for even more useful information. And as always, please share in the comments below any great tips and tricks that help you when treating individuals with dementia. Beck, C. Improving dressing behaviour in cognitively impaired nursing home residents. Nursing Research. Dooley, N. The American Journal of Occupational Therapy. Kolanowski, A. Efficacy of theory-based activities for behavioral symptoms of dementia.
Schaber, P. Thanks for letting me know! I removed the link and updated the article with more helpful resources. Thanks for the useful information. I have a question. If I have a patient on caseload as an OT with dementia and I am spending time to give education to the caregiver and train the caregiver. Is that time billable? Does the patient have to be present for it to be billable? At time is more appropriate to give education to the caregiver without the patient present due to the patient possibly getting agitated or anxious because they are unaware of their cognitive deficit.
Thank you! Hi Bethany! I personally am able to bill for caregiver education where I work but again, every facility seems to differ in what they allow for billing purposes.
It never hurts to ask! Hi Sarah, Thanks for this insightful information. I am a student OT, just six months into it. Please can you offer some insight as to how I would write the outcome when using music therapy as an intervention for clients with dementia? What outcome measure would you suggest? I am having difficulty understanding outcome and outcome measures. I hope this helps!
Your comment. This site uses Akismet to reduce spam. Learn how your comment data is processed. Occupational Therapy Interventions for Dementia. Once you get to know what works best for them, you can improve the outcome of your session.
How do we do this? Interventions for Middle Stage Dementia With middle stage dementia, the individual will have even more of a decline in memory and high level cognition. This may be due a legitimate lack of time or simply a lack of education of the caregivers. Interventions for Late Stage Dementia With late-stage dementia, individuals will be at their final stage of the disease process. Special Considerations From Personal Experience While keeping your interventions functional and meaningful, also keep in mind what is most beneficial for that individual client.
If your patient refuses to work with you or appears agitated, assess the environment. Is there excess stimuli? You may also like. Thanks in advance and I look forward to hearing from you soon. Leave a comment Cancel reply. My OT Spot uses cookies to improve your experience. If you are not OK with this, you can opt-out if you wish.
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