3.3 Non-pharmacological approach
3.3.1. Introduction
As it is mentioned on the first unit, most of the diseases that causes dementia currently has not cure. However, there are some pharmacological treatments (medicaments) and non-pharmacological interventions that can reduce or improve patients or individuals’ symptoms.
Non-pharmacological interventions or psychosocial interventions, are no-chemical therapies adequate to individual needs of participants that have a positive effect on their lives and their social and familiar environment. These interventions are based on scientific methods and they can be combined with pharmacological treatments to achieve better results.
3.3.2. Types of non-pharmacological interventions
There are a huge range of non-pharmacological interventions that can be applied according to needs of each person and his stage of dementia.
Throughout this unit different kind of therapies are analised. Some of them are specially created to improve cognitive functions of people with dementia (example: cognitive stimulation therapy), there are others more focused on improving daily living activities of patients (example: physical activity) and finally, there are some therapies whose aim in to improve individuals’ behaviour and wellbeing.
Engagement of people with dementia in activities and discussions enhances cognitive and social functioning. The most common form of cognitive stimulation encompasses group sessions led by a trained coordinator, for instance discussions about the past, events of the day, travel or food, word games and quizzes. Mounting evidence points out that cognitive stimulation programmes enhance cognitive function in people with mild to moderate dementia over and above any medication effects. The positive effects seem to maintain up to three months after the end of the treatment. Moreover, self-reported quality of life and wellbeing, communication and social interaction seem also to improve, whilst the effects of cognitive stimulation on mood disturbances, activities of daily living, problem behaviors or family caregiver outcomes are rather minimal. Interestingly, computer-based forms of cognitive stimulation have been shown to be equally effective as traditional ones.
Guided practice on standard tasks targeting memory, information processing speed or visuospatial ability are offered in individual or group sessions or alternatively in computerized form (digital tablets). Tasks of variable difficulty are available, so that they correspond to the individual’s capabilities, deficits and needs. Cognitive training may include learning of memory strategies (mnemonics). People with pre-dementia cognitive disorders seem to benefit more, but still moderately, from cognitive training in comparison to individuals suffering from dementia with regard to global cognition, attention and memory. The absence of demonstrable significant benefits may be attributed to methodological issues that have hampered research efforts to consider all potential gains that may be produced by cognitive training.
Cognitive rehabilitation is an individualized non-pharmacological therapeutic intervention focused on the identification of personally relevant and pragmatic goals that could be reachable by developing and implementing compensatory strategies in cooperation with the person with dementia and his/her family. It aims to improve performance in activities of daily living and does not focus on cognition per se. It has been reported that people with mild to moderate dementia benefit significantly from less than ten individual sessions of cognitive rehabilitation delivered by a specialized occupational therapist in the participants’ homes
Reality orientation aims to decrease confusion and behavioral symptoms in people with dementia by orienting the individual to time and place. Widely used, reality orientation often includes group sessions similar to those in a classroom and is usually held daily for 30 minutes. These sessions often present personal and current information to participants through the use of games, puzzles, calendars, and reality boards.
Reminiscence therapy elicits recall of past events, activities, and memories through the use of tangible aids such as photographs, familiar items from the past, music and movies. While remembering recent memories (e.g. what one had for lunch) may prove difficult for individuals with dementia, long held memories of personal importance can remain easily accessible. Reminiscence therapy encourages participants to speak about past experiences therefore decreasing the demand on impaired cognitive abilities while encouraging those preserved abilities. Evidence 13–20 suggests reminiscence is an effective means of improving mood in persons with dementia but results are mixed regarding a definite cognitive benefit. The intervention is administered in either a group setting, typically once/week focusing on free recall of memories or on an individual basis within the context of a focused life review.
Validation means to acknowledge the subjective view of individuals with dementia and to try to interpret their verbal and non-verbal expressions are prompted by and reflect straightforwardly personally relevant motives. It intends to validate the perceived reality and emotional experience of an individual. The therapist provides agreement, support, encouragement, empathy, praise and comfort. Despite several inconsistencies between research findings, a number of studies have observed a reduction of challenging behaviours and depressive symptoms. Of note, no effects on cognitive ability or activities of daily living were reported.
The improvement of the physical fitness of people with dementia is related to better performance on activities of daily living and lower caregiver burden. Despite the detected beneficial effects on several areas of cognition in people with pre-dementia cognitive impairment, the effects of physical exercise in the stage of dementia are questionable. As elderly people in general, individuals with dementia are advised to perform at least 30 minutes of moderate (aerobic) exercise on at least five days a week. Such a recommendation seems to be in many cases unrealistic.
Art therapy has been recommended as a treatment for people with dementia as it has the potential to provide meaningful stimulation, improve social interaction and improve levels of self-esteem (Reference Killick and AllanKillick & Allan 1999). Activities such as drawing and painting are thought to provide individuals with the opportunity for self-expression and the chance to exercise some choice in terms of the colours and themes of their creations.
More than listening to music, playing music activates several parts of the brain simultaneously. Emotions are stimulated, memories are awakened, the expression of feelings is fostered, social interaction is facilitated. Music therapy can take several forms. These encompass more passive approaches such as listening to music (recorded or live), providing a personalized (preferred music) music list on an iPod, or active approaches such as singing familiar songs in a group or playing a musical instrument. Music therapy ameliorates depressive and anxiety symptoms, agitation and challenging behaviors, whilst it maintains perceptual-motor skills. In contrast to passive music therapy, active music therapy, being more suitable for people with mild to moderate dementia, has been shown to improve general cognitive ability.
The use of pure essential oils from fragrant plants fosters relaxation and sleep, pain relief, amelioration of depressive symptoms, as well as aggressive tendencies and further challenging behaviors. Nonetheless, the observations of clinical trials seem to be somehow inconsistent.
Multi-sensory stimulation or „snoezelen“ is people in advanced stages of dementia. It is founded on the assumption that sensory deprivation leads to agitation, anxiety and/or aimless wandering. In multi-sensory stimulation the senses are addressed by lighting, colors’, touch, scents and sounds provided in adequately designed environments. Multi-sensory stimulation contributes to the amelioration of behavioral symptoms and mood disturbances during and immediately after the sessions. The efficacy of “snoezelen” in the long term is still elusive.
Bright light therapy (BLT) consists of exposure to daylight or specific wavelengths of light using polychromatic polarised light, laser, light-emitting diodes, fluorescence lamps, dichroic lamps or very bright, full-spectrum light.
Relying on the interplay between cognitive function, emotions and behavior, CBT interventions in dementia are focused on the development of behavioral strategies such as increasing the level of activity, introducing pleasant activities in daily routines, practical problem solving, and implementing compensatory strategies or tools. Such interventions contribute to the treatment of depressive and anxiety symptoms of people with dementia.
Interpersonal therapy, examines the individual’s distress within an interpersonal context (Reference Weissman, Markowitz and KlermanWeissman et al, 2000). In this sense, there is a great deal of overlap with the person-centred work. It uses a specific framework in which the individual’s distress is conceptualised through one of four domains: interpersonal disputes; interpersonal/personality difficulties; bereavement; and transitions/life events. Despite there being good empirical evidence of the success of this form of treatment with older people, it has only recently been used with dementia (Reference James, Powell and KendellJames et al, 2003).
Animal-assisted therapy (AAT) most commonly involves interaction between a patient and a trained animal, facilitated by a human handler, with a therapeutic goal such as providing relaxation and pleasure, or incorporating activities into physical therapy or rehabilitation. The therapeutic effect has been described by Baun and McCabe with reference to the stage of dementia and the positive effect on caregivers.