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Nonpharmacological interventions in care homes 

Nonpharmacological interventions in care homes
Nonpharmacological interventions in care homes

Ian A. James

and Jane Fossey

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In England, a third of the people with dementia live in care homes. The main provider of the 18,083 homes in England is the private sector, and residents tend to be accommodated in large 20- to 90-bedded facilities. In other countries, such as Sweden, the Netherlands, Austria, and Norway, smaller units are more common. Studies that have investigated the relative benefits of the different sizes of facilities are in the main inconclusive, but there are indications that structural and cultural differences affect the amount of symptoms of agitation shown by residents and the antipsychotic drug use in care homes (Testad, 2010).

The English National Dementia Strategy has called for a reduction in the percentage of people with dementia living at home seeking to support more people in their own homes for longer. The impact of this policy, which is already detectable in recent figures (Care Quality Commission, 2011), will change the nature of people entering care, with care facilities being required to cater for residents with more advanced levels of cognitive and physical impairment. While dementia and physical frailty are common reasons for entering care, noncognitive symptoms, such as agitation, psychosis, anxiety, and depression, are also determining factors. Agitation is a presentation within a wider cluster of symptoms referred to as either challenging behaviours (CB) or behavioural and psychological symptoms of dementia (BPSD); Table 21.1 outlines some of these common symptoms. Coping with these BPSD can be particularly taxing for families, leading to a point where families consider a move to a care home as the most appropriate action for themselves and their family member.

Table 21.1 List of common Challenging behaviours (CB)

Aggressive forms of CB

Nonaggressive forms of CB






Repetitive noise


Repetitive questions


Making strange noises


Constant requests for help


Eating/drinking excessively





Hair pulling

General agitation

Tripping someone

Following others/trailing

Throwing objects

Inappropriate exposure of parts of body

Stick prodding

Masturbating in public areas


Urinating in inappropriate places




Handling things inappropriately


Dismantling objects

Physical sexual assault

Hoarding things

Verbal sexual advances

Hiding items

Acts of self-harm

Falling intentionally

Eating inappropriate substances



In a study of 141 people with dementia over a 2-week period, the combination of apathy and agitation within individuals was found to be the most common phenomenon, with behaviour fluctuating during the day (Buettner and Fitzsimmons, 2006). An understanding of the different needs and how interventions may be best tailored to meet these is essential. Simply focusing on a single symptom (such as agitation) may compound the difficulties people face in expressing their needs. Figure 21.1 maps out a range of needs in a 3-D model. It attempts to capture the diversity along three different continua: an axis of good to poor physical health, an axis of good to poor cognitive health, and one for good to poor mental health. Whilst this model does not entirely account for the variations in symptoms within individuals, as described, it helps to focus attention on a number of contributing factors to be considered.

Figure 21.1 Three-axes representation of health.

Figure 21.1
Three-axes representation of health.

The complexity of the diagram can be reduced by demonstrating the core features within a grid (Table 21.2). In this grid we can see that there are eight broad groupings of presentation, each cell requiring a different treatment.

Table 21.2 Grid outlining the eight cells of the three axes model

No to little cognitive impairment

Moderate to severe cognitive impairment

Good physical health

  1. 1. Good mental health

  1. 3. Poor mental health

  1. 5. Good mental health

  1. 7. Poor mental health

Poor physical health

  1. 2. Good mental health

  1. 4. Poor mental health

  1. 6. Good mental health

  1. 8. Poor mental health

It is worth noting that the table is a simplified representation as it does not portray the variability implied by the three intersecting continua. However, the table helpfully demonstrates the types of presentations one finds in a care setting, from the least impaired residents (cell 1) to the most (cell 8). As one might expect, the needs of people within each cell will differ greatly, as will the mechanisms of providing psychosocial support. Indeed, those who are not suffering from BPSD will not require specific clinical treatments, but active steps will be required to ensure they do not develop distress. This is a very important point as it suggests that nonpharmacological input should be both preventative as well as reactive. Thus, even for residents in cell 1, care staff should be encouraged to provide opportunities for them to meet the basic needs of companionship and social activities to prevent the residents developing low affect. Similar requirements will be needed for those in cell 2, although these residents may require additional physical help to allow them to access such activities.

Those in the other cells will require additional specialist input depending on their mental and physical health needs. The people in the right-hand cells (5–8) will have the additional difficulties of cognitive problems, requiring trained staff to act on their behalf to ensure their needs are met. Owing to the great diversity of presentations, those providing psychological support should ideally be trained in a diverse range of interventions and management strategies.

It is important to recognize that these axes in Fig. 21.1 are not independent of one another, and a change on one may produce changes on others. As such, people can move between the cells, becoming better or worse with respect to a certain condition. For example, take a fictitious client called Morris. He was referred to clinical services because of his depression, poor mobility, and cognitive impairment (cell 8). Following successful treatment of the arthritis in his knees, he became more independent, his mood improved significantly, and he can be reclassified as having cell 5 status. In Morris’s case, the two latter features were both ‘reversible’ conditions, whereas his dementia was not significantly impacted by the changes. In this case, his cognitive impairment was seen as an ‘irreversible’ feature.

In many respects, the work of therapist is to determine what aspects of a resident’s presentation are reversible, and then use the correct techniques and skills to reverse them. In contrast, the irreversible conditions often require effective management strategies (palliative care, staff support, specialist equipment, etc.). It is important to note, however, that even when a condition is unlikely to be reversed, the person can benefit from identification and treatment of its psychosocial consequences (see the disability model of dementia; Ballard et al., 2001: 92). Consider Joan, who had experienced a stroke 5 years ago that left her with severe right-sided weakness. Unfortunately, the resulting mobility problems prevented her leaving the home to go to the day centre, go out with her family, walk in the home’s garden, etc. These were all activities that previously gave her good wellbeing. Although the stroke damage is irreversible, the problematic consequences of her poor mobility can be dealt with and, via the correct management, she should be able to go out and attend the day centre (training in use of walking frame, assisted-transport to the day centre) and gain access to the garden (installation of a ramp).

In many situations, it is features on the Mental Health axis of Fig. 21.1 that are the easiest to reverse and enhance (i.e. improvements in wellbeing and mood). For example, depressive symptoms have been found to be associated with disruptive vocalization, one of the forms of agitation often described as difficult to ameliorate in care homes (Dwyer and Byrne, 2000). Underlying depression has an impact on many neuropsychiatric symptoms. In a recent study of 105 long-term care home residents, the use of tailored recreational therapies addressing passive behaviour of people with dementia with depression and agitation showed a significant change in passive behaviour and apathy related to significant changes in agitation (Buettner et al., 2010). This is a key point, because they often can be the most neglected aspects in some of the ‘task-‘driven staff practices operating in care facilities. It could also be argued that good mental health is the most important status to achieve because if contentment can be obtained, even if one has dementia and a serious heart condition, a high quality of life can be experienced. The remainder of this chapter will focus on the methods used to improve people’s mental health status.

Current Treatment Regimens

Numerous UK reports have testified to problems with our existing service provision within care facilities (National Audit Office, 2007): e.g. poor leadership, inadequate staff training, and lack of opportunities of residents to engage in activities and past-times. The Alzheimer’s Society Home from Home report (2007) indicated that a typical person in care spent just 2 min interacting with staff or other residents over a 6-h period (excluding time on supported care tasks). Further, the English National Dementia Strategy criticised the lack of consistency in input from specialist mental health teams, and also raised concerns over the misprescribing of antipsychotics. Indeed, a UK government commission report by Banerjee (2009) highlighted this problem in detail. This watershed report stated that the antipsychotics, which were being used to treat CB with and without psychotic features, were largely ineffective and had major problematic side effects, including death. It recommended the reduction of the use of antipsychotics by 66% within a 3-year period—a target not met. One of the reasons for this is the perceived lack of nonpharmacological alternatives to medication with respect to the symptoms described in Table 21.2 (Wood-Mitchell et al., 2008). The Department of Health in the UK has issued some guidance about how to reduce antipsychotic use (Alzheimer’s Society, 2011). The section Nonpharmacological Strategies for Older People will provide more detail on some of these alternatives to psychotropics, together with their evidence bases A comprehensive account of these alternatives within a stepped-care framework has been produced (Brechin et al., 2013).

Nonpharmacological Strategies for Older People

There are an increasing number of therapies available for older people (Pachana, et al., 2010). In Cohen-Mansfield’s (2001) systematic review of psychological treatments, she classified eight types of intervention: sensory, social contact (real or simulated), behaviour therapy, staff training, structured activities, environmental interventions, medical/nursing care interventions, and combination therapies. She identified 83 nonpharmacological intervention studies via her search, although many were of a poor standard. Examining the effectiveness of interventions for people who are often physically frail and have dementia and/or anxiety and depression poses particular challenges. Studies address a range of different symptoms of mood or behaviour and use a wide range of outcome measures, which can make the findings difficult to compare. Specific problems relating to conducting research in the area include difficulties administering a conceptually discrete intervention package. There is often overlap between the various forms of therapy, and many will include a mixture of environmental, orientation, and staff-training features. Hence, it is difficult to determine which aspect of the package is the change element; such confounds also mean it is problematic comparing the forms of therapy with each other. It is often unfeasible to run double-blind studies due to the rather overt nature of the interventions and difficulty in devising placebo conditions. Despite this, there are a number of good quality randomized controlled trials (RCTs) and other experimental trials that are of high quality through ensuring fidelity to the intervention model (Kolanowski, 2006). Further published studies can be regarded as good practiced-based evidence. Table 21.3 provides an overview of some of the nonpharmacological approaches used with older people that have been reviewed systematically.

Table 21.3 Nonpharmacological approaches and their evidence base

I Preventative therapies

Systematic reviews and empirical status in dementia

Key articles

Reality orientation: uses rehearsal and physical prompts to improve cognitive functioning related to personal orientation. Tends to be used for people occupying cells 5–8 of Table 21.1.

A Cochrane review by Spector et al. (2002) identified six RCTs. The reviewers concluded there was evidence of improvements in terms of cognitive and behavioural features. RO is now assessed under cognitive stimulation therapy.

Verkaik et al. (2006)

Reminiscence therapy: involves discussion of past experiences individually or in a group format. Photographs, familiar objects, and sensory items used to prompt recall and discussion. Used with all presentations, cells 1–8.

A Cochrane review by Woods et al. (2005a, updated 2009) identified five RCTs, four containing extractable data. The reviewers reported significant results in terms of cognitions, mood, caregiver strain, and functional abilities. However, the quality of the studies was perceived to be poor.

Gibson (1994); Bohlmeijer et al. (2003)

Validation therapy: based on the general principle of acceptance of the reality of the person and validation of his/her experience. Used with people in cells 5–8.

A Cochrane review by Neal and Barton Wright (2003, updated 2009) identified three studies, two showing positive effects. However, the reviewers concluded there was insufficient evidence to view the approach as effective.

Finnema et al. (2000); Schrijnemaekers (2002)

Psychomotor therapy: exercises (e.g. walking and ball games) are used to target depression and behavioural difficulties. Used with all presentations, cells 1–8.

A Cochrane review by Montgomery and Dennis (2002) examining the impact of exercise on sleep problems identified one trial that demonstrated significant effects on a range of sleep variables. Forbes et al. (2008) found limited evidence that physical exercise slowed down cognitive decline.

Hopman-Rock et al. (1999); Winstead-Fry and Kijek (1999)

Multisensory stimulation: stimuli such as light, sound, and tactile sensations, often in specially designed rooms, used to increase the opportunity for communication and improved quality of experience. Used with people in cells 5–8.

A Cochrane review by Chung and Lai (2002, updated 2009) identified two RCTs. Despite some favourable results, the studies were so different that they could not be pooled. As such, the reviewers concluded there was insufficient evidence to view the approach as effective.

Baker et al. (2001); Van Weert et al. (2005) Please update and supply

Cognitive stimulation therapy: derived from RO, focuses on information processing rather than rehearsal of factual knowledge. Used with all presentations, cells 1–8, although developed for cells 5–8. In people with dementia, it tends to improve skills only in those areas that training has been given; otherwise it is of limited generalization.

Awaiting findings of a new review by Woods et al. (in press). The two previous reviews (Clare et al., 2003; Woods et al., 2005b) concluded that despite positive evidence there was insufficient evidence to view the approach as effective.

Spector et al. (2003, 2006); Woods et al. (2005)

Aromatherapy: use of essential oils to provide sensory experiences and interactions with staff. The oils can be administered via massage techniques or in patients’ baths. Used with all presentations, cells 1–8.

A Cochrane review by Holt et al. (2009) identified two RCTs, but only the Ballard et al. (2002) trial was reviewed. This trial, despite flaws, was viewed favourably in terms of reducing agitation and neuropsychiatric symptoms. Quynh-anh and Paton’s (2008) work showed equivocal results.

Ballard et al. (2002); Holmes et al. (2002)

Music therapy: includes playing and/or listening to music as a way of generally enhancing wellbeing. Can be used in movement therapies. Used with all presentations, cells 1–8.

A Cochrane review by Vink et al. (2009) identified five studies. However, the quality of the studies was poor. As such, the reviewers concluded there was insufficient evidence to view the approach as effective.

Lord and Garner (1993); Gotell et al. (2002)

Environmental manipulation: use of environmental cues, signage, and appropriate building layout in order to facilitate communication, exercise, and pleasure and to reduce disorientation. Developed for people in cells 5–8.

A Cochrane review by Forbes et al. (2009) on the use of bright light therapy in terms of mood, sleep, and behaviour reviewed three trials. However, the quality of the studies was poor. As such, the reviewers concluded there was insufficient evidence to view the approach as effective. A Cochrane review by Price et al. (2001, updated 2009) on the use of environmental and social barriers to prevent wandering failed to identify suitable trials.

Judd et al. (1997); Day et al. (2000)

II Intervention strategies (formulation-led approaches)

Behavioural management techniques/functional analysis (FA): based on learning theory and utilizing the antecedents and consequences of behaviour to devise and execute interventions. The approach has a long therapeutic tradition and can be applied to people in all cells, but as FA it has been targeted at cells 5–8.

A systematic review by Spira and Edelstein (2006) reported 23 studies. These tended to be of poor to moderate quality, and many were single case design. Moniz-Cooks et al.’s recent Cochrane review (2012) has identified 18 studies with weak but favourable evidence.

Moniz-Cook et al. (2011)

Psychotherapies: the use of CBT, IPT, and other standard psychotherapeutic formats. These methods have a good evidence base for people in cells 1–4. CBT has been shown to be highly effective in people with comorbid mental health and physical problems. Adaptions to people with dementia are recent developments, and will be limited to mild dementia.

Teri et al. (1997) demonstrated the positive impact of CBT on mood and problem-solving abilities in people with dementia. Teri and Gallagher-Thompson’s (1991) RCT revealed significant reduction in depression for both people with dementia and their carers. Scholey and Woods (2003) undertook CBT with seven people with dementia and depression, and identified key themes in such work.

Teri et al. (1991); Miller (2009)

The first group of approaches (I) are termed ‘preventative strategies’, and are generally designed to promote a positive therapeutic milieu and positive wellbeing. It is suggested that improving people’s general levels of contentment serves to improve mood, and reduces anxiety and the incidences of problematic behaviours. The second form of approach (II) is termed ‘intervention’, a reactive strategy, responding to a difficulty that has already been diagnosed (depression, anxiety) or observed (agitation, shouting, wandering), and the procedure is specifically targeted to intervene with the problem or its causes. These approaches routinely involve the development of a formulation to help understand the triggering and maintaining features of the problem. For example, behaviour management approaches pay particular attention to the function of the behaviour, examining in great detail the antecedents, characteristics, and consequences associated with its performance. The other formulation-based approaches often include careful observation of the behaviour, but also examine the distal features associated with the behaviour (e.g. the patient’s history, personality, physical health, staff interactions) (James, 2011).

In the following sections the various approaches will be described in more detail together with their evidence-base, including controlled and noncontrolled studies and the implications of the findings for treatment use.

Use of preventative approaches

These are designed to create an atmosphere and environment aimed at promoting the wellbeing of residents. Many of the approaches in this category could be termed person-centred in that they are designed to (1) support the strengths of residents, (2) focus on their difficulties, and (3) foster psychological health and validate their daily experiences (Brooker, 2007). In this section, the approaches will be discussed in descending order of the strength of their evidence-base. Thus initially we will discuss the more established and empirically tested therapies, and then methods for which the evidence is emerging but as yet not definitive.

Established preventative therapies

Reality orientation (RO)

RO is one of the most widely used management strategies in care homes, and particularly for people with dementia. The approach attempts to orientate residents to the ‘present’ via the use of cues (clocks, calendars, newspapers) and/or discussion. The rationale underpinning this strategy suggests that owing to memory and orientation problems, people with dementia are often confused and this may lead to social disengagement. However, if one is able to provide cues that enable them to engage in what is happening in the ‘here and now’, they are able to participate in conversations in a more confident and fulfilling way. The provision of environmental cues (e.g. signs, picture boards) also has the advantage of assisting residents with dementia to find their way around their setting. In recent years, RO has become less popular as concerns have been raised about the inflexible way in which it has been practised in some services. There is debate regarding the efficacy of the approach (Verkaik et al., 2005), even in light of Spector et al.’s (2002) favourable Cochrane review of six RCTs. The debate centres around claims that RO can remind the participants of their deterioration (Goudie and Stokes, 1989), and it can lead to repeated confrontations with the person with dementia (Brooker, 2001).

Cognitive stimulation therapy (CST)

CST has developed from RO and involves activating residents’ remaining cognitive functioning through the presentation of orientation information (e.g. use of physical games; word and number games; everyday objects—see Spector et al., 2006). Recent studies show promise for this approach for people with mild to moderate dementia (Knapp et al., 2006), and also demonstrate its cost effectiveness due to the fact that it can often be performed in a group setting. Livingston et al.s’ (2005) systematic review of six studies of various quality (e.g. Romero and Wenz, 2001; Spector et al., 2003) concluded that this approach consistently showed promise across a range of situations. This view was confirmed in a more recent expert review (Spector, 2008). There is a great deal of ongoing work examining the long-term effects of CST, patient acceptability, and the mechanisms of change associated with it. Much of this work is taking place under the Support at Home Interventions to Enhance Life in Dementia (SHIELD) research programme.

Reminiscence therapy (RMT)

RMT involves residents reliving past experiences, especially those that might be positive and personally significant, such as family holidays and weddings. This therapy can be used as a group therapy or with individuals. Group sessions employ activities such as art and music and often use artefacts to provide stimulation. RMT is seen as a way of increasing levels of wellbeing, providing pleasure and cognitive stimulation. When working with people with dementia, care staff and families are often encouraged to jointly construct historical reviews of the residents’ lives (i.e. life stories). Life story work is helpful in promoting attachments between staff and residents, particularly in cases where residents have poor communication skills. There is growing evidence that RMT is an effective treatment for older people with and without dementia (see Woods et al., 2005a and Bohlmeijer et al., 2003, respectively). Indeed, the approach has many supporters (Gibson, 1994; Brooker and Duce, 2000) due to its flexibility and adaptability to the individual’s needs (e.g. a person with severe dementia can still gain pleasure from listening to an old record). However, within the care home setting, studies continue to show mixed results for its effectiveness (e.g. Gudex, 2010; Hsieh, 2010) and careful consideration is needed of the aims for its use.

Validation therapy (VT)

VT was developed to address the perceived lack of flexibility of the RO approach with people with dementia. It was suggested by its originator, Naomi Feil, that some of the features associated with dementia such as repetition and retreating into the past were in fact active strategies to avoid stress, boredom, and loneliness. She argues that people with dementia can retreat into an inner reality based on feelings rather than intellect as they find their present reality too painful. VT therapists thus attempt to communicate with people with dementia through empathizing with the feelings and hidden meanings behind their confused speech and behaviour. It is the emotional content of what is being said that is therefore more important than the person’s orientation to the present. It is, however, suggested that therapists can become too focused on confused communication and fail to identify simple explanations such as pain and hunger. In a Cochrane review, Neal and Barton Wright (2003) evaluated VT’s effectiveness across a number of controlled trails, employing cognitive and behavioural measures (Finnema et al., 1998, 2000). They concluded that despite some positive indicators in terms of depression (Toseland et al., 1997), the jury was still out with respect to its efficacy. Subsequent small controlled studies (Deponte and Missan, 2007; Tondi et al., 2007) have found a reduction in behavioural disturbance and this approach may be helpful in addressing these signs of distress.

Environmental modification

Modifying environments to meet the needs of residents can be effective in improving wellbeing and reducing unwanted behaviours for people with dementia (Bowie and Mountain, 1997). By developing a psychosocial understanding of behaviour and its meaning for the person, the environment can be changed to meet his or her needs. The use of colour and structure in an environment can help with orientation (Gibson et al., 2004). Designing an environment with a more home-like atmosphere with good lighting and some environmental stimulation can reduce unwanted and agitated behaviours (Day et al., 2000). Access to safe gardens and outdoor spaces is also beneficial and opens up the possibility to develop horticultural-type therapies with residents. A comprehensive evidence-base has yet to be established in this area, although a number of controlled studies (Livingston et al., 2005) and a larger number of noncontrolled studies have shown environment and design to be important (Hulme et al., 2010; Zuidema et al., 2010).

Psychomotor therapy

Psychomotor therapy, sometimes referred to as activity therapy, is a rather varied group of action-based activities, such as dance, sport, and drama. A recent study by Cohen-Mansfield and colleagues (2010) demonstrated the positive impact of a range of such activities for residents in care. In this study, Cohen-Mansfield monitored the impact of 25 different tasks undertaken over a 3-week period (conversations, interactions with animals, use of toys, reading, listening to music, folding towels, flower arranging, puzzles, artistic activities, etc.). For each of the activities, both the amount of perceived enjoyment obtained from the task and the length of ‘time spent’ engaging in the task were assessed. The findings revealed that the most enjoyable tasks were those that involved engaging with living things (people, real baby, animals), followed by tasks involving some form of social simulation (use of dolls, simulation presence videos). However, when length of engagement was assessed (i.e. length of time spent on the task), the residents spent longer on tasks that mimicked work-like activities (stamping envelopes, sorting jewellery, folding towels). These results are likely to have important consequences in terms of the sorts of activities one might suggest to carers to help occupy people with dementia in order to enhance wellbeing, increase self-worth, and relieve boredom. A study of a drama and movement group showed positive outcomes in terms of increased communication (Hokkanen et al., 2003) and an earlier study showed moderate benefits in terms of relaxation and orientation (Wilkinson et al., 1998). The therapeutic use of touch occurring with activity programmes has also been found to reduce disruptive vocalizations (Woods et al., 2004). Despite these findings, two of the three better quality controlled trials conducted in the area failed to find significant differences in terms of depression and apathy when compared to treatment as usual (Hopman-Rock et al., 1999) and low ‘activity’ sessions (Dröes, 1991). However, the third study (Montgomery and Dennis, 2002) showed a positive impact of exercise on a range of sleep variables.


It has been shown that physical exercise can have a number of health benefits for older people in care settings. Vogel (2009) has reviewed the health benefits, which include a reduction in cardiovascular morbidity and mortality, optimization in blood pressure and lipid profile, improved executive function, cardiorespiratory fitness, and insulin sensitivity, decreased Aß42 plasma levels, increased bone density, and prevention of falls. Other benefits such as a slower rate of decline of activities of daily living have been shown to result from a simple exercise programme, 1 h twice a week (Rolland et al., 2007). Exercise has also been shown to increase older people’s mood and confidence (Young and Dinan, 1994; Singh et al., 2005). A major programme of research is currently underway in this area, and the studies are collectively known as the Seattle Protocols (Teri et al., 2008).

Multisensory therapy

Multisensory approaches usually involve using an activity room that has been designed to provide several types of sensory stimulation, such as light (often in the form of fibre optics which can move and be flexible), texture (cushions and vibrating pads), smell, and sound. The use of these resources is tailored to the individual person and therefore all of the forms of stimulation are not necessarily used in one session. Some of the reported benefits for those with more advanced dementia include a reduction in aggressive behaviours, apathy, and depression and an increase in interaction and signs of wellbeing (van Weert et al., 2005a, 2005b). However, individuals differ in their response to this treatment, with some studies failing to find an effect and some obtaining a negative one. The latter findings highlight the need for individualized assessments and planning (Hope, 1998). It is also possible to bring sensory experiences into the daily lives of people with dementia through the use of interesting and stimulating decoration, colour schemes, and textures in the environment, and the selection of personal care items, such as toiletries that are scented (Wenbourn, 2003). Chung and Lai’s (2002) Cochrane report of this therapy stated that, overall, the findings were, as yet, inconclusive. However, more recently, Verkaik et al.’s, (2005a, 2005b) review has suggested that multisensory approaches are particularly effective in the treatment of apathy and depression both in care and in the community. The elements of any programme can be difficult to evaluate, although this has been achieved in a study of ‘Simple Pleasures’, which investigated the effects of 30 handmade recreational items on the behaviour of nursing home residents with dementia, as well as the impact on family visits, staff knowledge, and volunteer involvement in the homes. Twenty-three items were found therapeutically valuable and there was some reduction in agitation. Family visits, use of recreational items, and satisfaction with visits significantly improved during the intervention (Buettner, 1999; Colling and Buettner, 2002). These US studies led on to the evaluation and development of a series of theory-driven protocols addressing sensorimotor, physical, social, cognitive, and psychosocial needs of people with dementia (Buettner and Fitzsimmons, 2009), for which there is growing evidence of effectiveness of the different elements. These have been adapted and are being evaluated in the UK as part of a National Institute for Health Research-funded research programme called Well-being and Health for People with Dementia (WHELD) which is running until 2015.

Alternative preventative psychological strategies


The two main essential oils used in aromatherapy for dementia are extracted from lavender and lemon balm. There have been positive results from recent controlled trials that have shown significant improvements in agitation symptoms with excellent compliance and tolerability (Ballard et al., 2002; Holmes et al., 2002). It is relevant to note, however, that Thorgrimsen et al.’s, (2003) review stated that there were flaws in both of these controlled studies, and thus the findings must be treated with caution. Furthermore, the latest study has found rather mixed results (Nguyen and Paton, 2008).

Music therapy

The poor quality of studies on this topic has been noted in a Cochrane review (Vink et al., 2009). Nevertheless, it has long been accepted within the scientific literature that music can have a profound effect on people’s mood and wellbeing (Sherratt et al., 2004). Indeed, music is used as a mood-inducing technique in a number of clinical trials, where the music produces a state that temporarily induces depression (Clark, 1983). Music is also considered useful in reducing unwanted behaviour and improving communication, particularly when tailored to people’s taste. For example, Lord and Garner (1993) showed increased levels of wellbeing, better social skills, and improvements in autobiographical memory in a group of residents interacting with bespoke music. Such improvements were not observed in a comparison group engaged in other activities. A sustained music therapy programme over 30 weeks has also demonstrated a reduction in scores on the Neuropsychiatric Inventory (Cummings et al., 1994)—in particular, reductions in agitation, delusions, anxiety, apathy, irritability, aberrant motor activity, and night-time behaviour disturbances, with improvements maintained at 1-month follow-up (Raglio et al., 2008). There have also been reported improvements in depressive symptoms through participation in reminiscence focused music groups (Ashida, 2002), and improvements in communication and irritability when engaged in structured playing of music (Suzuki et al., 2004). As with all strategies, care needs to be used when using this approach because music can cue problematic memories too (e.g. music of the 1940s reminding people of wartime losses).

Art therapy

Art therapy (drama, model making, drawing, and painting) is a treatment in which people have the opportunity to explore new skills (Mottram, 2003) and thereby enhance their self-esteem. In the case of people with dementia, art therapy has been shown to provide meaningful stimulation and improve social interaction and levels of self-esteem (Killick and Allan, 1999). Whilst many anecdotal studies suggest that this may be an activity that promotes wellbeing, there is limited evidence of its impact-specific conditions or of longer-term benefit when sessions stop.

Animal-assisted activities

Animals introduced into nursing homes as regular visitors or as home pets have been shown to have positive effects, including reducing blood pressure, agitation, strain, tension, and loneliness and increasing life-expectancy (Churchill et al., 1999). Short-term interactions with dogs have been shown to increase social interaction with, and between, older people with mental impairment (Greer et al., 2001). These forms of social contact have proven beneficial in the treatment of behaviour problems in dementia (Zisselman et al., 1996). The presence of other types of animal have also demonstrated benefits. For example, the use of a fish tank in a dining area has been shown to reduce aggression and enhance the nutritional intake of home residents with dementia (Edwards, 2004). However, the welfare of human and animal participants needs to be considered in any programme and guidance is becoming available on both infection control (Lefebvre et al., 2008) and on programme planning that incorporates considerations needed for all participants to achieve positive outcomes (Fossey, in press).

For situations when live animals are not appropriate, researchers have investigated the ability of robotic animals to provide companionship and increase quality of life in nursing home residents. Banks et al. (2008) examined the interactions of residents with Sony’s robotic dog ‘Aibo’ and found that both Aibo and a live dog reduced agitation, and both were equally effective in doing so. Similarly, Libin and Cohen-Mansfield (2004) had promising pilot results with both a robotic dog and a plush dog.

Using dolls and toys

The use of dolls and toys in care settings is not new (Libin and Cohen-Mansfield, 2004), but has only recently been studied in a systematic manner (James et al., 2005; Mackenzie et al., 2006a). Investigations have involved the introduction of dolls and teddy bears into care homes following a standard format (Mackenzie et al., 2006b). Typically, staff are given information and guidelines on their use prior to their introduction (Mackenzie et al., 2007). The findings from these investigations have been favourable for both residents and staff (James et al., 2006; Mackenzie et al., 2006a). However, this approach is controversial and an unresolved debate within the Journal of Dementia Care (Mackenzie et al., 2006c, 2007) has demonstrated resistance to the technique as it can be viewed as ‘patronizing’ and promoting ‘infantilization’.

Tool-box approaches

Some of the above strategies have been presented as stand-alone techniques, but it is evident that often carers combine them and use them in nonstandard ways. A good example of this is the various forms of ‘tool-box’ techniques (Thwaites and Sara, 2010). This widely used approach involves creating an individualized box of items for each person, containing personalized material (e.g. photographs, postcards, camcorder recordings of family scenes or voices, items of clothing, ornaments, relevant maps, aromatherapy oils). Carers, particularly care staff, can use the items in the box to stimulate and communicate with the individual, learning more about the person’s history and promoting positive reminiscence.

Intervention strategies

In the following section, a number of ‘formulation-led’ approaches are described. Here, typically a condition has already been observed (depression, problematic behaviour, etc.) and the intervention procedure is specifically targeted at its causes. These interventions routinely involve the development of a formulation (i.e. a descriptive account of the problem in relation to the person and his or her past) to help understand the triggering and maintaining features of the condition (James, 2010). First, some standard psychotherapeutic approaches will be described (cognitive behaviour therapy (CBT), interpersonal therapy (IPT)), whose use is limited to those in cells 1–4 of Table 21.2 (i.e. with up to mild impairment) (James, 2010). We will then go on to discuss therapies that can be used with all presentations (cells 1–8), even with cases of severe dementia (behaviour therapy (BT) and needs-led frameworks). It is relevant to note that the function of the formulation of the standard psychotherapies differs with that of the two latter therapies. For example, CBT and IPT formulations are designed to aid ‘clients’ gain a better understanding of their problems; this requires the clients to have a degree of insight into their difficulties and the ability to initiate change with respect to their behaviour. In contrast, BT and the needs-led frameworks employ formulations as vehicles to enable carers to gain a better understanding of the people with dementia’s difficulties. This is particularly important because in cases of severe dementia, it is the staff carers who are required to carry out the interventions.

Standard psychotherapies

Over the last 10 years there has been an increasing interest in applying CBT and IPT to older people, including those with cognitive impairment (Miller and Reynolds, 2007; James, 2010). In relation to people with dementia, these therapies are used in cases of low mood and anxiety or when the person retains some insight and problem-solving abilities. CBT examines people’s distress within a cycle (Fig. 21.2a and b); in order to alter the inner feeling, the outer features are worked on. The cognitive aspects (i.e. thoughts and beliefs) receive particular attention, because when people are distressed, they tend to engage in negative thinking (e.g. I am worthless; everyone hates me; no-one wants me). CBT has developed strategies to help people re-evaluate their thinking, and to start re-engaging in ‘helpful’ activities and relationships they have been avoiding (James, 2010).

Figure 21.2 Cognitive behaviour therapy triads

Figure 21.2
Cognitive behaviour therapy triads

It is relevant to note that this triad is also helpful in understanding the problematic behaviour of those with more severe dementia, with their behaviours linked to their distorted sense of their current reality (Fig. 21.2b). However, their cognitive deficits prevent them being able to make changes for themselves.

Teri and Gallagher-Thompson (1991) reported positive findings from a clinical trial of CBT with people in the early stages of Alzheimer’s disease. Single case and group CBT have also been used by other researchers with some favourable results (Koder, 1998; Kipling et al., 1999).

IPT, as the name suggests, examines the person’s distress within an interpersonal context. People are encouraged to look at how important relationships have changed since they have become distressed, and they are also asked to examine their communication styles to see if they can be improved. Such an approach is particularly relevant for those therapists who see challenging behaviours as a communication strategy in a form other people find socially unacceptable. For example, a person with poor verbal skills and reduced insight is unable to ask for food, and so he or she takes it from someone else. There is some overlap of IPT with the person-centred work of Kitwood (1997) and Stokes (2000). There is good empirical evidence for this form of treatment with older people (Miller and Reynolds, 2002); it has only recently been applied in the area of dementia (James et al., 2003; Miller and Reynolds, 2007; Miller, 2009; James, 2010). Owing to the demands IPT places on insightfulness and the ability to reflect, its use remains rather limited in the treatment of people with dementia.

Carer-centred, person-focused approaches

The following approaches can be employed for a range of clinical presentations, even in situations where clients have poor communication skills and/or poor insight; thus these methods are suitable for working with people with severe dementia. The key reason they can be employed with this group is that, although the focus of the treatment is directed at the person with dementia, much of the actual work is done via carers. Due to this, working with these interventions requires a systems approach, whereby much of the success depends on supporting the carers to deliver the therapy effectively. For this reason, the approaches are termed ‘carer-centred, person-focused’ (James, 2011).

Behaviour therapy

BT requires a detailed assessment period in which the triggers, behaviours, and reinforcers (i.e. the antecedents, behaviour, and consequences (ABC)) are identified and their relationships made clear. This process is frequently referred to as a functional assessment (Gormley et al., 2001; Moniz-Cook et al., 2012). The therapist will often use some kind of chart or diary to gather information about the manifestations of a behaviour (B) and the sequence of actions leading up to it (A). The reactions to the behaviour (C) are also studied because they frequently serve to either increase or decrease the likelihood of the action occurring again. Such monitoring helps to identify the function of CB, and the accurate observations are essential in generating better hypotheses. For example, consider the case of Joan, whose continual shouting was initially attributed to arthritic pain. However, the functional assessment revealed that she only shouted in the presence of men. This meant her painkillers could be stopped, which relieved her constipation, and the new data allowed the therapist to focus on her issues with men, enabling her therapists to go on to develop a more appropriate intervention.

Teri et al. (2005) developed and conducted an 11-session training programme to teach 41 carers of individuals with dementia how to manage agitated behaviour using functional analysis (FA)-based behavioural interventions in their home environment. During sessions, carers worked with a therapist to define problem behaviours, complete and interpret functional analyses, and develop interventions. Teri et al. (2005) presented four case studies to illustrate the effectiveness of their programme. The antecedents to the four participants’ agitation were found to be (1) lack of activity, (2) confrontation over confused statements, (3) inactivity specifically at dusk, and (4) lack of social attention due to the caregiver completing tasks, respectively. Consequently, antecedent control interventions were designed (e.g. providing appropriately tailored activities).

For one participant, the interventions resulted in the elimination of verbal and physical aggression. For the other three participants, reductions in agitated and aggressive behaviours were found. Unfortunately no data were presented and limited qualitative feedback from the participants were reported as outcome measures, making it difficult to interpret how successful the interventions actually were.

The efficacy of BT has been demonstrated in the context of dementia in a number of studies (Doyle et al., 1997; Baker et al., 2006) and reviews (Spira and Edelstein, 2006) A rigorous Cochrane review has recently been conducted by Moniz-Cook et al. (2012). Fifteen trials were identified, ten from family care settings and five from residential care settings. For the primary outcome of frequency of problematic behaviours, only 10 studies (n = 1140 participants) had usable data. They concluded that whilst FA showed promise, it is too early to provide an indication of its effectiveness. This is because the evidence rests largely on a handful of studies for which its actual effects are unclear, since the intervention tended to be delivered within broad multicomponent programmes of psychosocial interventions. Furthermore, the studies were generally small and the duration of interventions varied across studies.

Needs-led therapies

These approaches have often been developed for the treatment of CB. Currently, there are a number of conceptual models that examine cases of CB in terms of people’s needs (Cohen-Mansfield, 2000; James, 2011). These frameworks typically involve obtaining two types of information: (1) background features (history, premorbid personality and coping style, cognitive status, mental health status, physical health status, environmental and contextual status) and (2) a comprehensive description of the problematic behaviours—a functional assessment. By putting these two types of information together, one is in a stronger position to accurately identify the person’s needs. The needs-based models highlight the fact that CB are usually not unpredictable random actions; rather they are rational activities with a high degree of predictability. Indeed, frequently, CB are manifestations of residents’ attempts to fulfil an unmet need. For example:

  • CB as a method of trying to achieve a need (e.g. breaking a window in order to get outside of the care facility and walk in the garden)

  • CB as a means of fulfilling one’s need (e.g. urinating in a sink in order to relieve the pressure in one’s bladder)

  • CB as an expression of frustration that a need is not being met (e.g. hitting a member of staff who is insisting you go to bed when you are enjoying a late-night TV programme).

Cohen-Mansfield (2000) provides one of the best descriptions of an unmet needs model, and her recent empirical study testifies to the efficacy of her approach (Cohen-Mansfield et al., 2007). The fundamentals of her work are based on Maslow’s hierarchy of needs: the need for physiological/physical wellbeing; safety; love and belonging; esteem; and self-actualization. She believes that CB often occur when the ‘vulnerable and disadvantaged’ person strives to have some of these fundamental needs met. She believes that such striving is often problematic for people with dementia because of the following difficulties: poor communication; inability to use prior coping mechanisms; unable to meet own needs without the assistance of others. There are often additional difficulties because the person’s environment may not be able to provide the ‘need’, or the setting may simply not understand it.

Bird et al. (2007) are also exponents of the needs-led perspective, and have provided numerous case examples of the benefits of this methodology. More recently, Bird has undertaken a controlled study that illustrates the efficacy of his work (Bird et al., 2009).

Other frameworks using a cognitive behavioural model to aid staff in their understanding of how they may contribute to residents’ behaviour through a communication cycle have also been used with positive outcomes (Fossey et al., 2006; Fossey and James, 2008).

Staff Training

As demonstrated with carer-centred and person-focused approaches, staff are a vital piece of the jigsaw in delivering good care in homes. De Vugt et al. (2004), using a longitudinal design, showed that caregiving management strategies were associated with incidences and types of behavioural problems. For example, caregiver impatience, irritation, and anger towards residents were more likely to result in greater resident agitation. It is important that staff have an understanding of evidence for recreational and therapeutic interventions, the rationale of reducing medication that has potential to interfere with therapy effectiveness, and the need to individualize activities to maximize their benefit (Kolanowski, et al., 2009).

In terms of training, the methods of staff education have been varied and involved broad-ranging teaching programmes (Burgio et al., 2002) and use of reflective practice tools such as Dementia Care Mapping (DCM) (Kitwood, 1997) and operationalized person-centred care systems, defining practice in terms of value of people, individuality of care, perspective of service users, and positive social psychology (VIPS) (Brooker, 2007). These frameworks assess the activity and level of wellbeing from a resident’s standpoint, and provide information about caregiver interactions—from which action plans for care improvement can be developed. The DCM tool also acts as an audit of person-centred practice and has been used with positive results in some studies and had a more equivocal impact in others. The fact that it can be both intervention and outcome evaluation can make its true worth difficult to assess, but it has good face validity and is generally well received by practitioners (Brooker, 2007).

In general, evidence shows that staff can be trained to deliver better care (Opie et al., 2002; Schrijnemaekers et al., 2002), but the effects do not tend to generalize across care activities and they tend to fade with time. Owing to concerns about the limited long-term impact of training, it appears that employing training interventions alone may not be the best use of clinical time unless the training is supported by continued supervision and organizational development.

Of late, a number of studies have attempted to improve the status of care by intervening at the organizational level. For example, relatives have been encouraged to work alongside staff and get involved in care planning, delivery, and review. The results have been mixed, with family members having difficulties in sustaining their involvement (Gaugler et al., 2004; Train et al., 2005). On balance, the organizational studies show limited evidence of sustained improvement in culture, attitudes, or the quality of care (Aylward et al., 2003).

Programmes that have taken a broader organizational focus in implementing person-centred care in combination with training and mentoring have been shown to have some benefits on medication use in the Focused Intervention Training and Support Programme (Fossey et al., 2006; Fossey and James, 2008), and some aspects of quality of life in the VIPS model of care (Brooker, 2007) and the Enriched Opportunities Programme (Brooker, 2011). Individual care home groups have also implemented their own programmes of organizational and cultural change; one example, the PEARL programme (Baker et al., 2009), is based on the VIPS model (Brooker, 2007) and uses a cycle of audit, training, and organizational change to achieve clearly defined standards of care. In the UK, there has been support from the Department of Health and Alzheimer’s Society to test the feasibility of the roll-out of a structured programme (Fossey and James, 2008) to a larger number of homes in order to address the general concerns that are raised about care delivery.


Having reviewed many of the treatments currently available, it is worth noting the commonalities between the various interventions. Indeed, in many of the studies the treatments employed similar mechanisms of change, often promoting activities, cognitive stimulation, and person-centred approaches. From our perspective, and an examination of the modus operandi of many of the treatments presented, good communication skills and an ability to interact positively are key to those studies that have demonstrated positive effects. This is because many residents in care homes find it an isolating experience, due to a combination of the losses experienced (social networks, familiar environment and routines) and cognitive (memory and orientation) problems resulting from dementia. Therefore, when a therapist or staff member engages with a resident, using activities, photographs, music, an animal, doll, massage, etc., their level of interpersonal contact rises considerably. For many residents, this will result in an increase in mood and wellbeing. It is also our view that the formats provided within the various approaches provide staff with specific structures that aid the staff’s ability to communicate. This feature was particularly evident in the studies using dolls (James et al., 2005), in which staff reported that the dolls gave them a focus of conversation. It is relevant to note that in the above study, many staff admitted that they often found speaking to people with dementia difficult.

The present chapter has also shown that there is a general move towards more person-centred and staff-centred foci of care. Through the use of such perspectives, greater attempts are now made to understand the individual’s experience of his/her problem within an intrapsychic, interpersonal, and environmental context (Bond and Corner, 2001). It is this perspective that leads to a further shared feature with respect to the interventions: that is, the systemic perspective. Onishi et al. (2006), in a large survey of three different types of Japanese care facilities, found that the incidences and forms of problematic behaviours differed across settings. The carers’ abilities to cope with the behaviours also varied. From their findings, the researchers suggested that such systemic knowledge of the resilience of such settings was crucial in determining the appropriateness of placements and transfers. Therefore, it is clearly important to recognize how the context of a person with dementia’s relationships with family and caregivers affects both individuals with dementia and their caregivers. Such a view emphasizes the need to work with all of the systems involved in the residents’ care (families, professional carers, organizations, etc.). Indeed, care staff and families are integral to the treatment strategies and are essential in obtaining valid and reliable information and constructing appropriate formulations and interventions. It is evident therefore that carer/staff training is an integral part of most treatment programmes. Despite the relevance of this issue, there remain relatively few ‘quality’ studies in the area (e.g. Moniz-Cook et al., 1998; Proctor et al., 1999; Marriot et al., 2000—see also Cohen-Mansfield et al., 1997). Clearly, training and support is an important area worthy of further work, and such studies need to be large and sufficiently powered, with robust designs that include follow-up methods. The latter issue is given particular emphasis in the NICE guidelines on dementia (2006), with specific mention of the need to develop and deliver person-centred educational programmes. Finally, it is evident from this review that the evidence base underpinning nonpharmacological interventions is growing and can offer alternatives to inappropriate medication and be used in combination with medication to improve care for residents with dementia.

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