A nondrug approach to dementia

CASE Ms. M becomes markedly delirious while in the hospital after hip surgery, and a geriatrics consultation is requested. This is not surprising, given that underlying dementia increases a patient’s risk of delirium in the hospital.²⁷ The geriatrician recommends several measures to reduce the likelihood of delirium—providing good pain control, minimizing night time wake-ups, minimizing Foley catheter use, Hep-locking the IV to encourage mobility, and having staff reorient her frequently by referring to a large print clock and calendar on the wall.

Specific interventions

Most specific nonpharmacologic therapies have not been robustly studied in randomized controlled trials. But a series of smaller studies have been evaluated in systematic reviews. The level of evidence for each intervention is summarized in TABLE 1.^28-40

As you review the options that follow, keep 2 things in mind: (1) It is important to set realistic expectations when considering these approaches (as well as pharmacologic ones). Reducing the frequency or severity of problematic behaviors may be more reasonable than their total elimination.^6,25 (2) Consider targeting specific symptoms when treating behavioral  Behavioral symptoms most often occur when dementia enters the intermediate phase, but they may occur at any time during the course of the disease. disturbances.^2,24,41 Such targeting allows physicians and families to better evaluate the effectiveness of interventions because it helps to focus the discussion of the patient’s progress at follow-up visits.

Massage/touch therapy. A 2006 Cochrane review concluded that improvement in nutritional intake and hand massage, when combined with positive encouragement during a meal, may produce a short-term positive effect on agitation.²⁹ Similarly, a meta-analysis of randomized controlled and randomized crossover studies found a statistically significant improvement in agitation with hand massage, although this finding was based on the same single study referenced in the 2006 review.³⁰ Opinions differ among 5 high-quality guidelines included in the systematic review by Azermai et al regarding the value of massage, with 2 of the 5 practice guidelines recommending its use.²⁸

Aromatherapy. Several trials suggest that aroma therapy may reduce agitated behaviors. Lemon balm and lavender oils have been the most commonly studied agents. Two systematic reviews cite the same 2002 randomized controlled trial, which found a reduction in behavioral problems in people who received arm massage with lemon balm compared with those who received arm massage with an odorless cream.^30,31 A systematic review by Holt et al also cites a study that found lavender oil placed in a sachet on each side of the pillow for at least one hour during sleep seemed to reduce problem behaviors.³¹ Several evidence-based guidelines have concluded that aromatherapy may be helpful, and 2 of the 5 practice guidelines reviewed by Azermai et al recommend it.²⁸

Exercise has been shown to benefit patients of all ages, even those with terminal diseases.⁴² Some studies have indicated a positive effect of physical activities on behaviors ranging from wandering to aggression and agitation. Activities have included group gentle stretches, indoor exercises, and a volunteer-led walking program that encouraged hand holding and singing.³⁴ However, a 2008 Cochrane review concluded that the effect of exercise on behavioral disturbances in dementia has not been adequately studied.³⁵

Music therapy. Numerous types of music therapy have been studied, including listening to music picked out by a patient’s family based on known patient preference, classical music, pleasant sounds such as ocean waves, and even stories and comforting prayer recorded by family members. While most of these smaller studies yielded positive results,³⁴ a 2003 Cochrane review concluded there is not enough evidence to recommend for or against music therapy.⁴³ A more recent meta-analysis suggests that music may be effective for agitation.³⁰ A systematic review of quality guidelines also indicates that most of these guidelines rate the evidence as moderate to high in favor of music and 3 of 5 practice guidelines recommend it.²⁸

Nonphysical barriers have long been used as a creative nonrestraining method of preventing wandering. They include such tricks as camouflaging exits by painting them to look like bookcases, painting a black square in front of an elevator to make it look like a hole, and placing a thin Velcro strip across doorways. Although it would appear from a limited number of small studies and anecdotal evidence that nonphysical barriers work, a Cochrane review concluded that they have not been studied enough to perform a meta-analysis.³⁶

Cognitive stimulation typically consists of activities such as reviewing current events, promoting sensory awareness, drawing, associating words, discussion of hobbies, and planning daily activities. This type of therapy has been shown to improve cognition in patients with dementia, as well as well-being and quality of life. It does not improve behavioral problems, per se.³⁷