Nondrug Therapy Useful in Managing Agitation in Dementia

Deborah Brauser

December 08, 2014

Several nonpharmacologic interventions can help manage agitation in individuals with dementia ― at least in the short term, new research suggests.

Dr Gill Livingston

A review of 33 randomized controlled trials (RCTs) of dementia patients in care homes showed that training the staff in personalized care and better communication skills decreased agitation both immediately and for up to 6 months.

Music therapy and sensory intervention also reduced these symptoms in the short term, but there was little evidence that they worked in the long term. Unfortunately, exercise and aromatherapy did not result in any significant reductions in agitation in this patient population, and light therapy may actually be harmful.

"There are several interventions to try, but we should really be thinking about the individual person and why they might be agitated ― rather than thinking agitation is the same in everybody," lead author Gill Livingston, MD, MBChB, FRCPsych, from the Division of Psychiatry at University College London in the United Kingdom, told Medscape Medical News.

"We can't cure dementia, but we're at least being able to tackle some of the distressing symptoms of it. This is a really important part of managing the illness, and I feel passionately that we can make cognitive life better," added Dr Livingston.

The study was published in the December issue of the British Journal of Psychiatry.

Helplessness, Anger

Almost 50% of all individuals with dementia show symptoms of agitation every month, report the investigators.

"Agitation in dementia is...unpleasant, impedes activities and relationships, causes helplessness and anger in family and paid caregivers, and predicts nursing home admission, where the agitated behavior adversely influences the environment," they write.

With an aim to systematically review RCTs that examined nonpharmacologic interventions for dementia-related agitation, the researchers assessed 33 studies. Scores of 40 or higher on the Cohen- Mansfield Agitation Inventory and 5 or higher on the Neuropsychiatric Inventory agitation scale were used to signify agitation.

Results showed that training paid caregivers in person-centered care, better communication skills, and adapted dementia care mapping significantly reduced severe patient agitation immediately (standardized effect size [SES] range, 0.3 – 1.8) and for 3 to 6 months posttreatment (SES range, 0.2 – 2.2).

These interventions focus on ways to better talk with a patient, to find out what they want, and to treat them as individuals and not just as tasks.

Three of the reviewed studies evaluated music therapy by trained therapists and showed significant, immediate reductions in agitation (SES range, 0.5 – 0.9). However, there was little long-term evidence, and no evidence at all, of benefit for severe agitation.

"If you have moderate dementia and feel bad but don't know why, music can interest you and help to take your mind off things. And while it is playing, you'll often feel better. But afterwards, nothing has really changed," said Dr Livingston.

"On the other hand, if you're in a care home and the staff understands you and you understand them, then you'll generally feel better and less lonely and upset. That's why it might work better over the long term," she added.

Five sensory intervention studies targeted "perceived understimulation" of the participants.

"Some focused on touch, such as massage; others were multisensory interventions of tactile, light and auditory stimulation, such as Snoezelen therapy," report the investigators.

First Systematic Review

Therapeutic touch, "a healing-based touch intervention focusing on the whole person," was significantly efficacious before and after analyses, but not when compared with ordinary massage or treatment as usual.

Although sensory interventions significantly improved overall and symptomatic agitation during treatment, there was not enough evidence regarding long-term effects or effects in outpatient settings, such as in a residential home.

In patients with some or significant agitation, light therapy did not show significant improvements and sometimes even increased agitation, which was a finding that surprised Dr Livingston.

"I could see why it might work because of melatonin changes in the brain. But then I began to think: having bright light shown on you could be very uncomfortable for some people."

Two RCTs examined the effects of aromatherapy. The nonblinded study showed significant improvement in the group receiving aromatherapy compared with a control group; but the large, blinded study showed neither immediate nor long-term benefits.

"I was not surprised that aromatherapy did not work, because people with Alzheimer's can't really smell things," Dr Livingston noted.

The investigators report that "there was insufficient evidence to make a definitive recommendation" for exercise or simulated presence therapy, in which a recording mimicking a phone conversation with a loved one is played.

"This is the first up-to-date systematic review to focus on agitation," write the researchers, adding that the findings show that there are at least some evidence-based, beneficial strategies for care homes.

However, they note that future research should focus on long-term results and on determining which interventions work in a patient's home.

Still, "our findings suggest that clinicians should stop considering agitation as an entity but instead often as a symptom of lack of understanding or unmet need that the person with dementia is unable to explain," write the investigators.

First-Line Therapy

"I thought this review was well done, although I could quibble with a few details," Pierre N. Tariot, MD, director of the Banner Alzheimer's Institute in Phoenix, Arizona, and research professor of psychiatry at the University of Arizona College of Medicine, told Medscape Medical News.

Dr Pierre Tariot

Some of the limitations he cited were that the investigators excluded all studies that had a medication arm, and they excluded a large multisensory study recently conducted in the United States by the Alzheimer's Disease Cooperative.

"But those are just details. I think this helps contribute to what I hope will be a gradual shift in thinking that there are alternatives to medicines that can be helpful for these kinds of distressing and disruptive behaviors," said Dr Tariot, who was not involved with this research.

He agreed with the investigators that more studies are now needed on long-term effects and on what happens when people are still in residential homes.

"Is it possible to achieve enduring effects? And what does it take to do that? Creating a different culture where the expectation is the way that one communicates with or feeds or leads into activities in an ongoing manner can create enduring change," he said.

Dr Tariot noted that it is also important to realize that once a patient starts showing these types of symptoms, going into a care home is not the only option. Instead, there are several things that a family caregiver can do.

He added that his center does a lot of work to train families on communication and behavior management techniques, on focusing on positive events, and on distraction, extinction, and minimizing distressful moments.

"The take-away is that we should always be thinking about nondrug interventions first and foremost because they can actually be effective. Just reaching for the prescription pad is not necessarily the only or even the better solution."

The study authors have reported no relevant financial relationships. Dr Tariot reported no relevant financial relationships with regard to this review, but he did report that he has been principal or site investigator on a large number of industry and National Institutes of Health–funded trials of medications for treating agitation in patients with dementia.

Br J Psychiatry. 2014;205:436-442. Full article

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