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To what extent can dementia be treated using psychological interventions?

Dementia is a widespread and extremely debilitative syndrome that affects at least 5 million
people in Europe and causes great distress to patients, their families and their caregivers
(Waldemar et al., 2007). Dementia-type disorders cause cognitive impairment and decline
as well as behavioural disturbances which worsen over time (Teri et al., 1992), causing sharp
declines in patients independence, quality of life and cognitive and behavioural functioning
(Waldemar et al., 2007). Treatments for dementia vary considerably in their methods and
application: pharmacological therapies are commonly used, particularly in more severe
cases (Waldemar et al., 2007), and typically attempt to slow cognitive decline, though some
medications are thought to also reduce behavioural and psychological symptoms of
dementia (BPSD; Ballard & OBrien, 1999). However, due to the unpleasant and risky sideeffects of dementia medications such as donepezil and rivastigmine (Farlow, Miller &
Pejovic, 2008) a number of psychological interventions have also been developed to reduce
the cognitive and behavioural symptoms of dementia, with resulting treatments ranging
from ineffectual to well-supported and beneficial (Livingston, Johnston, Katona, Paton &
Lyketsos, 2005). However, even the more beneficial psychological interventions have
limitations in their application.

This review will look at some of the most promising psychological interventions and
treatments for dementia patients. Treatments that treat the cognitive symptoms of
dementia, i.e. cognitive impairment that increases in severity as the disease progresses, will
be examined first in terms of their techniques, their effects and their efficacy. Psychological
interventions that attempt to target and reduce BPSD will also be discussed. Finally, the
limitations of psychological, non-pharmacological treatments for dementia will be reviewed
independently and in comparison to pharmacological treatments. At this stage it is
important to note that this review will focus primarily on the cognitive and behavioural
symptoms of Alzheimers disease, the most common form of dementia disorder (Farlow et
al., 2008), to avoid having to deal with the range of different types of dementia and their
various symptoms.
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Also, for the purposes of this review treatment will refer to the reduction of symptoms
like cognitive impairment and behavioural problems and to delaying the progression and
worsening severity of symptoms, as dementia itself is currently incurable. Psychological
interventions will be defined as measures taken to reduce the symptoms of dementia and
improve dementia patients quality of life through cognitive and behavioural, nonpharmacological approaches.

Progressive cognitive decline is the main symptom of dementia (Teri, McCurry, Edland,
Kukull & Larson, 1995). The rate of decline varies from patient to patient, but the specific
cognitive impairments caused by Alzheimers and other dementias are common to the
majority of patients: episodic memory, verbal fluency, memory retrieval, attention capacity,
reading and writing, language comprehension, and visuospatial ability are all impaired by
the characteristic decline in cognitive abilities (Waldemar et al., 2007). Other effects of the
cognitive decline in dementia patients include echolalia, perseveration, disinhibition and
impairment of everyday cognitive tasks such as face-name association (Waldemar et al.,
2007; Acevedo & Loewenstein, 2007). These cognitive impairments can be very distressing
for dementia patients and increase their reliance on caregivers for day-to-day functioning
whilst reducing their self-confidence (Clare & Woods, 2004). As such, the cognitive
symptoms of dementia are distressing for patients and caregivers and have resulted in a
number of psychologists devising psychological interventions to improve cognitive
functioning in patients and to slow their decline.

Cognitive-focused psychological interventions have been studied as ways to treat the


cognitive symptoms of dementia for some time (Clare & Woods, 2004). Interventions that
attempt to treat cognitive symptoms of dementia are primarily limited to early-stage
dementia patients memory remains relatively intact during this stage (particularly
semantic and procedural memory) and thus permits greater learning than is possible in later
stages (Clare & Woods, 2004; Husband, 1999). However, such interventions may still
provide significant benefits to those able to receive them.

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A variety of cognitive tasks have been employed in cognitive interventions, with some
specifically designed to involve realistic everyday tasks (Acevedo & Loewenstein, 2007), and
three main approaches to cognitive interventions have been taken training, stimulation
and rehabilitation (Clare & Woods, 2004). Whilst cognitive training relies solely on the
repetition of cognitive tasks and is considered to have little longitudinal benefit (possibly
due to insensitive application in study trials or because trials failed to look at improvements
to quality of life; Clare & Woods, 2004), cognitive stimulation which uses more advanced
information processing techniques to stimulate general cognitive and social functions
(Livingston et al., 2005) has been shown to have prolonged positive effects on cognitive
ability in dementia patients (Farlow et al., 2008). Cognitive rehabilitation treatments use
similar cognitive techniques but focus specifically on maximising remaining cognitive
abilities on day-to-day tasks that are particularly important to patients, such as making
change and putting names to faces (Clare & Woods, 2004). Rehabilitation therapies are
supported by studies that found long-lasting benefits to cognitive processing and functions
over six months (Duara, Barker, Loewenstein & Bain, 2009) and to face-name association
memory twelve months after initial treatment (Clare, Wilson, Carter, Roth & Hodges, 2002)
in Alzheimers disease patients.

There is clearly some evidence that cognitive stimulation and rehabilitation can be effective
interventions in the early stages of dementia by enhancing cognitive functions to reduce the
impact of gradual cognitive decline. It is also possible that cognitive interventions can
provide similar benefits to patients with more advanced dementia, as cognitive stimulation
in particular has produced positive effects in patients with moderate Alzheimers disease
(Clare & Woods, 2004). A combination of cognitive stimulation therapy and reality
orientation in which patients are provided with reminders of orienting details such as
names, dates and the time to improve everyday cognitive performance has been
suggested as an effective intervention for more severe dementia patients, but evidence for
its efficacy is inconsistent (Clare & Woods, 2004; Livingston et al., 2005). Overall it appears
that cognitive symptoms can be treated with psychological interventions, but the limitations
of those interventions should and will be addressed later.

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Although cognitive impairment is the primary symptom of dementia disorders, behavioural


symptoms of dementia are also important and cause distress and impairment in dementia
patients in their everyday life (Cummings, Mackell & Kaufer, 2008). The estimated
prevalence of behavioural and psychological symptoms of dementia (BPSD) varies from 66%
prevalence (rising to 80% in care-home patients; Lawlor, 2002) to 85% prevalence (Lyketsos,
2007), but behavioural symptoms of dementia do exist as an issue for many patients. BPSD
for dementia disorders like Alzheimers disease include agitation, aggression (Sloane et al.,
2004), psychotic symptoms including persecutory delusions and hallucinations (Eccles,
Clarke, Livingston, Freemantle & Mason, 1998), social withdrawal (Zeisel et al., 2003),
depression, sleep disruption (McCurry, Reynolds, Ancoli-Israel, Teri & Vitiello, 2000) and
purposeless activities such as wandering and rummaging (Waldemar et al., 2007). These
symptoms drastically reduce quality of life for patients and increase carer burden to the
extent that it hastens institutionalisation (Lyketsos, 2007).

In response to the distress caused by BPSD and the relative health risks of medications such
as neuroleptics (for psychotic symptoms) and cholinesterase inhibitors (for more general
behavioural as well as cognitive issues) when treating persistent behavioural and
psychological issues (Sahakian & Morein-Zamir, 2007; Waldemar et al., 2007), a wide range
of psychological interventions have been used to try to reduce such symptoms in dementia
patients. Whilst many interventions and therapies have failed to show consistently positive
results (Livingston et al., 2005) a number of psychological treatments are well-supported
and show potential for use in dementia interventions. Cognitive stimulation therapy was
found to produce a long-lasting reduction of BPSD (Livingston et al., 2005), reinforcing the
belief that cognitive symptoms and BPSD interact (Teri et al., 1995). Environmental
modifications of the patients living area have been used to reduce specific BPSD:
environmental interventions include giving patients more privacy to reduce agitation and
aggression as well as improving sleep, camouflaging exits to reduce elopement, making
common areas appear more homely to decrease social withdrawal, and personalising the
sensory inputs of patients to reassure them with familiar sights and sounds and to reduce
sensory confusion, which is intended to reduce agitation as well (Zeisel et al., 2003). There is
evidence that obscuring exits can produce lasting reductions in agitation and that increased
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privacy can decrease aggression and anxiety for prolonged periods but the efficacy of other
environmental manipulations is uncertain due to inconsistent research findings (Zeisel et al.,
2003; Livingston et al., 2005).

Other psychological interventions include music therapy, which involves playing familiar
music and encouraging patient participation in producing and enjoying music, and
Snoezelen therapy, which combines relaxation and exploration of familiar and calming
sensory stimuli, both of which reduce agitation and other behavioural disruptions during
and immediately after therapy sessions (Livingston et al., 2005). Additionally, the education
of caregivers in patient-centred approaches to day-to-day care tasks such as bathing (a
major source of agitation and aggression in dementia patients; Sloane et al., 2004),
communication and the handling of sleep disturbances produce significant reductions in
aggression, agitation and depression (Sloane et al., 2004; Livingston et al., 2005).

Although evidence is somewhat mixed for some forms of psychological treatment of


dementia symptoms, it should be apparent that there is considerable evidence for a variety
of effective interventions for the treatment of cognitive and behavioural symptoms in
dementia patients. There are, however, significant limitations to the use of psychological
interventions in the treatment of dementia.

Firstly, whilst evidence for treatments like cognitive stimulation and psychosocial training
for caregivers does exist and is relatively consistent, the overall evidence for psychological
treatments for dementia remains insufficient to resolve the inconsistencies that do exist
psychologists continue to disagree over the efficacy of different treatments and it remains
unclear as to whether or not treatments like cognitive stimulation therapy have effects on
cognition and behaviour that last for long enough to have a significant impact on patients
long-term disruptive symptoms (Lawlor, 2002; Clare & Woods, 2004; Livingston et al., 2005).
There are also important practical limitations on the use of psychological interventions in
dementia: many proposed interventions involve the education of caregivers and their
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employment of repeated and time-consuming therapies and activities, and although family
carers could be expected in general to be invested sufficiently to commit to these measures
it is possible that care home staff will not be as dedicated (McCurry et al., 2000).

The additional resources in terms of money and staff that would be required for these
psychological interventions would also discourage care homes from using them (especially
due to the relative lack of support for psychological treatments compared to clinical drug
trials for pharmacological therapies), despite the fact that if they were successful they
would increase the independence of patients and thus reduce the resources and staff
required to deal with disruption caused by cognitive and behavioural malfunctions (Lawlor,
2002). The burden of stress and anxiety that comes from caring for dementia patients is
likely to act as another practical obstacle to caregiver interventions, as the interventions
would require even more effort for tired and stressed caregivers, without the use of
therapies aimed to reduce the burden of carers, which do exist but are not always effective
at producing long-term benefits (Eccles et al., 1998). Finally, the usefulness of psychological
treatments for dementia symptoms is greatest when treating mild to moderate symptoms
and is relatively unproven for severe cognitive and behavioural problems. The side-effects of
cholinesterase inhibitors like donepezil are considerable but there are also significant
benefits to medication use that are more likely to be effective at dealing with difficult
symptoms such as severe psychosis (Farlow et al., 2008), and drug treatments are also
relatively inexpensive and straightforward to use.

Cognitive and behavioural symptoms of dementia can be treated effectively using a number
of psychological interventions: however, due to issues with inconsistent research support,
practical costs, time consumption and limited utility, psychological interventions should be
used in conjunction with pharmacological treatments and should be researched further to
provide greater support for particularly promising interventions (Acevedo & Lowenstein,
2007; Livingston et al., 2005).
2000 words.
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