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Ageing Research Reviews 9 (2010) 163–183

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Ageing Research Reviews


journal homepage: www.elsevier.com/locate/arr

Review

Personalized dementia care: Proven effectiveness of psychosocial interventions


in subgroups
L.D. Van Mierlo a, H.G. Van der Roest a,b, F.J.M. Meiland a, R.M. Dröes a,b,*
a
VU University Medical Center, Department of Psychiatry, Alzheimer Center, EMGO Institute for Health and Care Research, Valeriusplein 9, 1075 BG Amsterdam, The Netherlands
b
VU University Medical Center, Department of Nursing Home Medicine, Alzheimer Center, EMGO Institute for Health and Care Research, Valeriusplein 9, 1075 BG Amsterdam,
The Netherlands

A R T I C L E I N F O A B S T R A C T

Article history: Many psychosocial intervention studies report effects in subgroups of people with dementia. Insight into
Received 25 May 2009 the characteristics of these subgroups is important for care practice.
Received in revised form 9 September 2009 This study reviews personal characteristics of people with dementia (living in the community or in an
Accepted 14 September 2009
institution) that are related to positive outcomes of psychosocial interventions. Electronic databases and
key articles were searched for effect studies published between January 1990 and February 2008.
Keywords: Outcome measures were clustered into categories such as cognitive functioning, behavioural
Dementia
functioning and mental health. Seventy-one studies showed positive outcomes on psychosocial
Information system
Care
interventions, such as decreased depression and less behavioural problems, related to personal
Welfare characteristics of people with dementia, such as gender, type or severity of dementia, presence of
Personalization behavioural or mental health problems, and living situation.
Outcome studies For people with dementia living in the community positive effects were most frequently found in the
persons with mild to severe dementia not otherwise specified and with mild to moderate Alzheimer’s
Disease. For people with dementia living in an institution positive effects were found most frequently in
the subgroups moderate to severe dementia, severe to very severe dementia and in the subgroup with
behavioural problems.
This study provides a unique overview of characteristics that are related to effective intervention
outcomes. It also suggests that more research will lead to a better understanding of which care and
welfare interventions are effective for specific subgroups of people with dementia.
ß 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction not expected to grow at the same rate as the expected increase of
people with dementia.
The number of people who are over 65 years of age and In a recent large survey, persons with dementia reported unmet
diagnosed with dementia will rise over the next decades. It is needs most frequently in domains of information about their
estimated that 7.3 million people in Europe (Alzheimer Europe, health and available care and welfare services, memory support,
2009) and 24.3 million people worldwide have dementia today, company and psychological distress (Van der Roest et al., 2009a).
and that the number of people affected will almost double every 20 Reasons for not using the available care and welfare services are
years to 42.3 million in 2020 and 81.1 million people in 2040 (Ferri that persons with dementia and their caregivers are often unaware
et al., 2005). This growth will put a major claim on health care of the care offerings available to them, they find it difficult to
services, especially the diagnostic, therapeutic, and preventative choose between all the different care services and therefore tend
health care services provided for individuals in the community, as not to use them, have negative experiences with the care received
well as on welfare services that aim to socially support these because it does not fit their specific situation or wishes, or they
persons and their carers. Persons with dementia need a lot of care anticipate that the service offer will not meet their needs (Van der
and the main problem here is that the amount of available care is Roest et al., 2009b).
Unmet needs can lead to many negative outcomes such as
mood and behavioural problems, unsafe situations, social isolation
and higher mortality for patients (Gaugler et al., 2005).
* Corresponding author at: VU University Medical Center, Department of
Psychiatry, Alzheimer Center, EMGO Institute for Health and Care Research,
To be able to provide people with dementia with the
Valeriusplein 9, 1075 BG Amsterdam, The Netherlands. Tel.: +31 20 7885454. appropriate care, the offer of available care and welfare services
E-mail address: rm.droes@vumc.nl (R.M. Dröes). should be optimally tailored to the specific individual needs of

1568-1637/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.arr.2009.09.002
164 L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183

persons with dementia. We therefore recommend more detailed caused disagreement between the researchers were discussed
investigation of the effectiveness of care interventions for until they reached agreement on inclusion or exclusion. Disagree-
subgroups. The findings could also benefit healthcare professionals ment could occur when it was not fully clear from the abstract
who offer care to people with dementia, as they will gain more whether the criteria were met, e.g.: the abstract lacked details on
insight into the effectiveness of different psychosocial interven- the characteristics of subgroups. In those cases the full text article
tions for subgroups of people with dementia. Many reviews in the was considered and discussed to decide on inclusion or exclusion.
past (e.g. Eggermont and Scherder, 2006; Livingston et al., 2005; Seventy-one studies described effective interventions for
Smits et al., 2007) have tried to give an overview of effective persons with dementia. Forty-five were institution-based and 26
psychosocial interventions, but failed to systematically provide were community-based interventions.
information concerning characteristics of the subgroups for which
those interventions have proven to be beneficial in particular. This 3. Results
information is important for professional health carers to be able to
provide advice or effective care that is attuned to the needs of their 3.1. Outcome measures
individual clients.
The aim of this study is to identify which personal and Characteristics of community-dwelling people with dementia,
contextual features (characteristics) are relevant to promote a institutionalized people with dementia and positive effects on
more effective and efficient use of care and welfare services for outcome measures were described. Because effect sizes were often
subgroups of persons with dementia. This is expected to result in not mentioned in the traced articles, we decided to not include
people with dementia making more efficient and successful use of these in the tables. For each subgroup several different categories
care services. With this study, we will provide a unique and of outcome measures were distinguished. The interventions for
comprehensive overview of personal characteristics that are people with dementia were divided into community-based and
related to positive outcomes of psychosocial interventions. institution-based interventions. The interventions under study
Examples of personal characteristics and contextual factors that were aimed at many different outcome measures. These outcome
may be related to effective care are: severity and type of dementia, measures for people with dementia living in the community
and availability of caregivers. (community-based care) and for people with dementia living in an
To gain insight into characteristics that are related to effective institution were clustered into six categories: ‘‘Quality of Life’’,
intervention outcomes this literature review focuses on the ‘‘Cognitive Functioning’’, ‘‘Behavioural Functioning’’ ‘‘Mental
following research question: Health’’, ‘‘Physical Health’’ and ‘‘Other Positive Outcomes’’
(Tables 1 and 2, first column). The clusters were formed based
Which specific characteristics of persons with dementia or their partly on research by Van der Roest et al. (2007).
situations are related to positive outcomes of individual care
and welfare interventions? 3.2. Outcomes of effective interventions for people with dementia
living in the community
2. Method
Table 1 (column 2) shows an overview of the programmes for
2.1. Literature search procedure and studies on people with dementia living in the community
included in the review, as well as the characteristics of people with
To find out which personal characteristics of persons with dementia living in the community that relate to positive outcomes
dementia are related to predictors of effective care and support on specific needs categories. In the reviewed studies, most of the
interventions we performed a literature study. This study was positive intervention effects were found in the subgroups of people
limited to non-pharmacological interventions. with mild to moderate dementia, moderate to severe dementia
We started by searching the electronic databases of PubMed, (not otherwise specified) and mild to moderate AD. The positive
PsycINFO and Cinahl. The inclusion criteria were studies that intervention effects were most often found to be related to the
report on the effectiveness of care and welfare services used by outcome categories cognitive functioning and behavioural func-
people with dementia, as well as on the relation between outcomes tioning. The fewest positive effects were reported on the outcome
and personal context characteristics. An intervention was con- category physical health.
sidered effective when it had a statistically significant positive
outcome for people with dementia living in the community or in an 3.3. How to use the tables
institution. Reviews were aimed at two groups of subjects, i.e.
people with dementia living in the community and people with The tables can be used in multiple ways. First, the tables can be
dementia living in an institution. used to find the appropriate intervention for an unmet need of a
The search was limited to reviews published between January person with dementia living in the community. Step 1 is to locate
1990 and February 2008. To structure the literature search, we the desired outcome effect of an intervention in the first column
used three categories: ‘‘dementia’’, ‘‘person with dementia’’, and (effects column). After locating the problem or unmet need,
‘‘effective care and support’’. For each category a search strategy column 2 (intervention column) shows what intervention(s)
was developed, based on keywords (Mesh, Thesaurus and Tree) create(s) the desired outcome. The numbers in the row(s) directly
and free text words. More detailed information is available on to the right of the appropriate intervention correspond with the
request from the authors. number of the publication in which positive effects on subgroups
were described (see references). The subgroup characteristics
2.2. Search results described in the studies are indicated in the top of the column.
A different way of using the table is to start from a specific
The initial search resulted in a total of 269 reviews, of which 32 subgroup of people with dementia experiencing a specific
met the inclusion criteria. These reviews were further analyzed problem, and then find the intervention that is most effective
and resulted in a total of 170 studies that described effective care for them. Take, for example, people with moderate to severe
and welfare interventions for patients with dementia. The Alzheimer’s Disease who experience depression. Using the table
abstracts were double-checked by two researchers. Abstracts that will lead the reader to an intervention that was effective in
Table 1
Characteristics of people with dementia living at home related to effective intervention outcomes.

Community-based care Type of dementia: Dementia not otherwise specified

Patient characteristics Dementia Severity Behavioural Other specific characteristics


problems
Mild to Moderate Living with No care use Intervention Intervention
moderate to severe caregiver at baseline in large in small
group group

Effects Intervention
Quality of life
Increased well-being Reminiscence therapy 5
Increased positive affect Music Memory Lane 14 14
Video Memory Lane 14 14 14
Decreased boredom Multisensory stimulation/activity 1 1
group
Increased calmness Video respite therapy

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Cognitive functioning memory problems
Increased performance on memory tasks Progressive muscle relaxation
Cognitive stimulation program
Improved memory for words Cognitive support: self-generated cues
Increased ability to recognize faces Errorless learning Intervention
Improved memory scores Individualized intervention 66
(information, coping)
Increased (I)ADL function Procedural memory stimulation
Decreased time used for ADL

Cognitive functioning cognitive problems


Improved problem solving Cognitive stimulation program
Slower cognitive decline Reality orientation therapy (ROT) 13
Enhanced cognitive functioning Alzheimer rehabilitation by students
Improved learning abilities
Improvement on generic biographical knowledge
Enhancement of score on picture description task

Cognitive functioning speech problems


Increased conversational quality Prosthetic memory aid
Increased performance on verbal fluency tasks Progressive muscle relaxation
Improved speech skills Activity group 1 1
Increased use of (different) nouns Alzheimer rehabilitation by students

Behavioural functioning not otherwise specified


Decreased behavioural disturbances Progressive Muscle Relaxation
Meeting Centers Support program 90
Improved behaviour Multisensory stimulation 1 1

Behavioural functioning social behaviour


Decreased non-social behaviour Meeting Centers Support program 90
Increased spontaneous talking Multisensory stimulation/activity 1 1
More initiative group 1 1
Decreased passivity Therapeutic recreation 7 7
interventions (TRI) at home
Decreased inactivity Meeting Centers Support program 90
Improved physical role functioning Reducing Disability in Alzheimer’s
Disease (RDAD)
Improved engagement with activity Music Memory Lane 14 14
for longer time period Video Memory Lane 14 14
Absence of hyperactivity Association with companion
animal

165
166
Table 1 (Continued )

Community-based care Type of dementia: Dementia not otherwise specified

Patient characteristics Dementia Severity Behavioural Other specific characteristics


problems
Mild to Moderate Living with No care use Intervention Intervention
moderate to severe caregiver at baseline in large in small
group group

Behavioural functioning aggressive agitated behaviour


Decreased aggression Home-based caregiver (skill) 9
Decreased verbal aggression training 9
Association with companion
Absence of verbal aggression animal
Decreased agitation Home-based caregiver (skill) 9
training
Therapeutic recreation 7 7
interventions (TRI) at home

Behavioural functioning repetitive behaviour

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Decreased repetitive verbalizations Carer training to implement
behaviour management programs
Decreased fidgeting Music Memory Lane 14 14

Mental health
Decreased depression Behavioural therapy
Nighttime Insomnia Treatment
and Education for Alzheimer’s
Disease (NITEAD)
Alzheimer rehabilitation by students
Behavioural therapy (pleasant events)
Meeting Centers Support program 90
Reducing Disability in Alzheimer’s
Disease (RDAD)
Decreased anxiety Progressive muscle relaxation
Absence of anxiety Association with companion animal
No hallucinations
Fewer mood disorders
Improved mood Multisensory stimulation/Activity 1 1
Increased alertness group 1 1
Increased self-esteem Meeting Centers Support program 90

Physical health
Improved physical health Reducing Disability in Alzheimer’s
Disease (RDAD)
Alzheimer rehabilitation by students
Increased strength
Decreased night wake time Nighttime Insomnia Treatment and
Decreased number of night awakenings Education for Alzheimer’s Disease
More exercise days (NITEAD)

Other positive outcomes


Delay of nursing home placement Prince Henry Hospital dementia 4
caregivers’ training programme
Individual and family counselling
Meeting Centers Support program 55
91
Reality orientation therapy (ROT) 13
Longer follow up procedure possible Prince Henry Hospital dementia 4
caregivers’ training programme
Community-based care Type of dementia: Alzheimer’s Disease

Patient characteristics Alzheimer’s Probable Severity Behavioural Gender Other specific characteristics
Disease AD problems

Mild to Moderate to Women Spending much High attachment


moderate AD severe AD time with to companion
companion animal
animal

Effects Intervention
Quality of life
Increased well-being Reminiscence therapy
Increased positive affect Music Memory Lane
Video Memory Lane
Decreased boredom Multisensory stimulation/
activity group
Increased calmness Video respite therapy 11

Cognitive functioning memory problems


Increased performance on memory tasks Progressive muscle relaxation 16 16

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Cognitive stimulation program 15
Improved memory for words Cognitive support: 10
self-generated cues
Increased ability to recognize faces Errorless learning Intervention 6
Improved memory scores Individualized intervention
(information, coping)
Increased (I)ADL function Procedural memory stimulation 19
Decreased time used for ADL 87

Cognitive functioning cognitive problems


Improved problem solving Cognitive stimulation program 15
Slower cognitive decline Reality orientation therapy
(ROT)
Enhanced cognitive functioning Alzheimer rehabilitation by 20
Improved learning abilities students 20
Improvement on generic biographical 20
knowledge
Enhancement of score on picture 20
description task

Cognitive functioning speech problems


Increased conversational quality Prosthetic memory aid 2 2
Increased performance on verbal Progressive muscle relaxation 16 16
fluency tasks
Improved speech skills Activity group
Increased use of (different) nouns Alzheimer rehabilitation by 20
students

Behavioural functioning not otherwise


specified
Decreased behavioural disturbances Progressive Muscle Relaxation 16 16
Meeting Centers Support
program
Improved behaviour Multisensory stimulation

Behavioural functioning social behaviour


Decreased non-social behaviour Meeting Centers Support
program
Increased spontaneous talking Multisensory stimulation/
More initiative activity group
Decreased passivity Therapeutic recreation
interventions (TRI) at home

167
168
Table 1 (Continued )

Community-based care Type of dementia: Alzheimer’s Disease

Patient characteristics Alzheimer’s Probable Severity Behavioural Gender Other specific characteristics
Disease AD problems

Mild to Moderate to Women Spending much High attachment


moderate AD severe AD time with to companion
companion animal
animal

Decreased inactivity Meeting Centers Support


program
Improved physical role functioning Reducing Disability in 17
Alzheimer’s Disease (RDAD)
Improved engagement with activity Music Memory Lane
for longer time period Video Memory Lane
Absence of hyperactivity Association with companion 8
animal

Behavioural functioning aggressive

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


agitated behaviour
Decreased aggression Home-based caregiver (skill)
Decreased verbal aggression training
Association with companion 8
Absence of verbal aggression animal 8
Decreased agitation Home-based caregiver (skill)
training
Therapeutic recreation
interventions (TRI) at home

Behavioural functioning repetitive


behaviour
Decreased repetitive verbalizations Carer training to implement 3
behaviour management
programs
Decreased fidgeting Music Memory Lane

Mental health
Decreased depression Behavioural therapy 18
Nighttime Insomnia Treatment 12
and Education for Alzheimer’s
Disease (NITEAD)
Alzheimer rehabilitation by 20
students
Behavioural therapy 77
(pleasant events)
Meeting Centers Support
program
Reducing Disability in 17
Alzheimer’s Disease (RDAD)
Decreased anxiety Progressive muscle relaxation 16
Absence of anxiety Association with companion 8
No hallucinations animal 8
Fewer mood disorders 8
Improved mood Multisensory stimulation/
Increased alertness Activity group
Increased self-esteem Meeting Centers Support
program
L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183 169

decreasing depression in that subgroup of people with dementia


living in the community, in this case Reducing Disability in
Alzheimer’s Disease (RDAD) (Teri et al., 1997). A third way to use
the table is mainly for health professionals who practice a certain
intervention. They can find specific subgroups of people in the
table who are likely to benefit in particular from their intervention.

3.3.1. Quality of life


Four studies described interventions, namely reminiscence
therapy (Brooker and Duce, 2000), Music Memory Lane and Video
Memory Lane (Olsen et al., 2000), multisensory stimulation or
activity group (Baker et al., 2001) and video respite therapy (Lund
et al., 1995), that succeeded in improving quality of life in
subgroups of people with dementia living in the community (i.e.
people with mild to moderate dementia, people with moderate to
severe dementia, people with dementia living with their caregiver,
people with dementia participating in interventions in a large or
small group setting and people with Alzheimer’s Disease). The
following personal characteristics of people with dementia living
in the community were related to positive intervention effects:
severity and type of dementia, and the living situation (alone, with
a partner, with an animal).

3.3.2. Cognitive functioning


Cognitive functioning was further delineated by identifying the
17

categories memory problems, cognitive problems (not otherwise


specified) and speech problems.

3.3.2.1. Memory problems. Seven studies described interventions,


namely progressive muscle relaxation (Suhr, 1999), cognitive
stimulation programme (Quayhagen and Quayhagen, 2001),
74
20
20

cognitive support (self-generated cues) (Lipinska et al., 1994),


errorless learning (Clare et al., 2000), individualized intervention
(information and coping) (Moniz-Cook et al., 2008) and procedural
memory stimulation (Zanetti et al., 1997, 2001), that succeeded in
decreasing memory problems in subgroups of people with
dementia living in the community (i.e. people with probable AD,
people with AD and behavioural problems, people with mild to
moderate AD and people with dementia that were not using care at
baseline). The following personal characteristics of people with
12
12

12

dementia living in the community were related to positive


intervention effects: type and severity of dementia, presence of
Meeting Centers Support program
Individual and family counselling

Reality orientation therapy (ROT)


Prince Henry Hospital dementia

Prince Henry Hospital dementia

behavioural problems and current care use.


caregivers’ training programme

caregivers’ training programme


Nighttime Insomnia Treatment
and Education for Alzheimer’s
Alzheimer’s Disease (RDAD)
Alzheimer rehabilitation by

3.3.2.2. Cognitive problems (not otherwise specified). Three studies


Reducing Disability in

described interventions, namely cognitive stimulation (Quayhagen


and Quayhagen, 2001), reality orientation therapy (Metitieri et al.,
Disease (NITEAD)

2001) and Alzheimer rehabilitation by students (Arkin, 2003), that


decreased cognitive problems in subgroups of people with
students

dementia living in the community (i.e. people with mild to


moderate dementia, people with Alzheimer’s Disease and people
with mild to moderate AD.) The following personal characteristics
of people with dementia living in the community were related to
positive intervention effects: type and severity of dementia.

3.3.2.3. Speech problems. Four studies described interventions,


namely a prosthetic memory aid implementation (Bourgeois,
Longer follow up procedure

1990), progressive muscle relaxation (Suhr, 1999), an activity


Decreased night wake time
Decreased number of night
Improved physical health

group (Baker et al., 2001), and Alzheimer rehabilitation by students


Other positive outcomes
Delay of nursing home

(Arkin, 2003), that succeeded in decreasing speech problems in


More exercise days
Increased strength

subgroups of people with dementia living in the community (i.e.


Physical health

awakenings

people with moderate to severe dementia, people with dementia


placement

living with their caregiver, people with probable AD, people with
possible

mild to moderate AD, people with AD and behavioural problems,


and people with AD that are women). The following personal
characteristics of people with dementia living in the community
170 L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183

were related to positive intervention effects: type and severity of characteristic of people with dementia living in the community
dementia, gender, presence of behavioural problems and living was related to positive intervention effects: type of dementia.
situation.
3.3.4. Mental health
3.3.3. Behavioural functioning Eight studies described interventions, namely behavioural
Behavioural functioning was further delineated by identifying therapy (Teri et al., 2003), Nighttime Insomnia Treatment and
the categories behavioural functioning (not otherwise specified), Education for Alzheimer’s Disease (NITEAD) (McCurry et al., 2005),
social behaviour, aggressive agitated behaviour and repetitive Alzheimer rehabilitation by students (Arkin, 2003), Behaviour
behaviour. therapy (pleasant events) (Teri, 1994), the Meeting Centres
Support Programme (Dröes et al., 2004b), Reducing Disability in
3.3.3.1. Behavioural functioning (not otherwise specified). Three Alzheimer’s Disease (RDAD) (Teri et al., 1997), association with a
studies described interventions, namely progressive muscle companion animal (Fritz et al., 1995), and multisensory stimula-
relaxation (Suhr, 1999), Meeting Centres Support Programme tion or activity group (Baker et al., 2001), that succeeded in
(Dröes et al., 2004b) and multisensory stimulation (Baker et al., improving mental health in subgroups of people with dementia
2001), that succeeded in improving behavioural functioning not living in the community (i.e. people with mild to moderate
otherwise specified in subgroups of people with dementia (i.e. dementia, people with moderate to severe dementia, people with
people with mild to moderate dementia, people with moderate to dementia and depression at baseline, people with dementia living
severe dementia, people with dementia living with their caregiver, with their caregiver, people with Alzheimer’s Disease, people with
people with probable AD and people with AD and behavioural mild to moderate AD, people with moderate to severe AD, people
problems). The following personal characteristics of people with with AD who spend much time with a companion animal and
dementia living in the community were related to positive people with AD who have a high attachment to a companion
intervention effects: type and severity of dementia, presence of animal). The following personal characteristics of people with
behavioural problems and living situation. dementia living in the community were related to positive
intervention effects: type and severity of dementia, presence of
3.3.3.2. Social behaviour. Six studies described interventions, depression and living situation.
namely the Meeting Centres Support Programme (Dröes et al.,
2004b), multisensory stimulation and activity group (Baker et al., 3.3.5. Physical health
2001), therapeutic recreation interventions at home (Fitzsim- Three studies described interventions, namely Reducing Dis-
mons and Buettner, 2002), Reducing Disability in Alzheimer’s ability in Alzheimer’s Disease (RDAD) (Teri et al., 1997), Alzheimer
Disease (RDAD) (Teri et al., 1997), Music Memory Lane and Video rehabilitation by students (Arkin, 2003) and Nighttime Insomnia
Memory Lane (Olsen et al., 2002), and association with a Treatment and Education for Alzheimer’s Disease (NITEAD)
companion animal (Fritz et al., 1995), that succeeded in improving (McCurry et al., 2005), that succeeded in improving physical
social behaviour in subgroups of people with dementia living in health for subgroups of people with dementia (i.e. people with
the community (i.e. people with mild to moderate dementia, dementia and agitation, people with Alzheimer’s Disease, people
people with moderate to severe dementia, people with dementia with mild to moderate AD, and people with moderate to severe
living with their carer, people with dementia participating in a AD). The following personal characteristics of people with
small or large intervention group, people with moderate to severe dementia living in the community were related to positive
AD and people with dementia who spend much time with a intervention effects: type and severity of dementia and presence
companion animal). The following personal characteristics of of agitation.
people with dementia living in the community were related to
positive intervention effects: type and severity of dementia and 3.3.6. Other positive outcomes
living situation. Five studies described interventions, namely Prince Henry
Hospital dementia caregiver’s training programme (Brodaty et al.,
3.3.3.3. Aggressive agitated behaviour. Three studies described 1997), Individual and family counselling (Mittelman et al., 1996),
interventions, namely home-based caregiver (skill) training Meeting Centres Support Programme (Dröes et al., 2004a,b), and
(Huang et al., 2003), association with a companion animal (Fritz reality orientation therapy (Metitieri et al., 2001), that resulted in
et al., 1995), and therapeutic recreation interventions at home the following other positive outcome: delay of nursing home
(Fitzsimmons and Buettner, 2002), that succeeded in decreasing placement for the subgroups of people with mild to moderate
aggressive agitation behaviour in subgroups of people with dementia and mild to moderate AD. The following personal
dementia living in the community (i.e. people with moderate to characteristics of people with dementia living in the community
severe dementia, people with dementia and behavioural problems, were related to positive intervention effects: type and severity of
people with dementia and agitation, people with dementia living dementia.
with their caregiver, people with Alzheimer’s Disease and people
who spend much time with a companion animal). The following 3.4. Outcomes of effective interventions for people with dementia
personal characteristics of people with dementia living in the living in an institution
community were related to positive intervention effects: type and
severity of dementia, presence of agitation, presence of beha- Table 2 (column 2) shows an overview of the programmes for
vioural problems and living situation. and studies on people with dementia living in an institution
included in the review, as well as the characteristics of people with
3.3.3.4. Repetitive behaviour. Two studies described interventions, dementia living in an institution that are related to positive
namely Carer training to implement behaviour management outcomes.
programmes (Bourgeois et al., 1997) and Music Memory Lane In all of the reported studies, most of the positive intervention
(Olsen et al., 2000), that succeeded in decreasing repetitive effects were found in the subgroups people with moderate to
behaviour in subgroups of people with dementia living in the severe, severe to very severe dementia (not otherwise specified)
community (i.e. people with dementia participating in a large and in people with behavioural problems. The positive interven-
intervention group and people with AD). The following personal tion effects were most frequently related to the outcome category
L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183 171

behavioural functioning, especially aggressive and agitated beha- characteristics of people with dementia living in an institution
viour. The fewest positive effects were found on the outcome were related to positive interventions effects: type and severity of
category quality of life. dementia.

3.4.1. Quality of life 3.4.3. Behavioural functioning


Six studies described interventions, namely a snoezel care plan Behavioural functioning was further delineated by identifying
(Van Weert et al., 2005: snoezelen can be defined as an approach the categories behavioural functioning (not otherwise specified),
which actively stimulates the senses of hearing, touch, vision and social behaviour, aggressive agitated behaviour and repetitive
smell in a resident-oriented, non-threatening environment. It is behaviour.
offered in a special room or integrated in 24 h care), person-
centred showering and a towel bath (Sloane et al., 2004), Sensory 3.4.3.1. Behavioural functioning (not otherwise specified). Fourteen
stimulation activities (Witucki and Twibell, 1997), a resident dog studies described interventions, namely snoezelen (Holtkamp
(McCabe et al., 2002), simulated presence therapy (Camberg et al., et al., 1997), morning bright light therapy (Mishima et al., 1994),
1999), and music during bathing (Clark et al., 1998), that daytime social interaction with nurses (Okawa et al., 1991), Special
succeeded in improving quality of life in subgroups of people Care Units Program (Bianchetti et al., 1997), Special Care Units
with dementia living in an institution (i.e. people with severe to (SCU) (Bellelli et al., 1998), A.G.E. Dementia Care Program (Rovner
very severe dementia, people with dementia and agitation, people et al., 1996), Expressive Physical Touch with Verbalization (EPT/V)
with dementia and withdrawn behaviour, people with dementia (Kim and Buschmann, 1999), Behavioural Management Program
and aggression during bathing, people with AD and aggression (DeYoung et al., 2002), skill elicitation (Rogers et al., 1999),
during bathing and people with severe to very severe AD). The reminiscence therapy (Namazi and Hayes, 1994), reminiscence
following personal characteristics of people with dementia living therapy (Gibson, 1994), Behavior Management Program (DeYoung
in an institution were related to positive intervention effects: type et al., 2002), person-centred showering (Sloane et al., 2004), and
and severity of dementia, presence of behavioural problems and music during bathing (Clark et al., 1998), that succeeded in
presence of mental health problems. improving behavioural functioning not otherwise specified in
subgroups of people with dementia living in an institution (i.e.
3.4.2. Cognitive functioning people with moderate to severe dementia, people with severe to
Cognitive functioning was further delineated by identifying the very severe dementia, people with dementia and behavioural
categories memory problems, cognitive problems (not otherwise problems, people with dementia and agitation, people with
specified) and speech problems. dementia and sleep disorders, people with dementia and irregular
sleep-wake rhythms, people with dementia and high ADL
3.4.2.1. Memory problems. One study described an intervention, dependency, people with dementia and aggression during bathing,
namely music therapy (Lord and Garner, 1993), that succeeded in people with AD and aggression during bathing, people with
decreasing memory problems in the subgroup of people with dementia participating in mixed intervention groups of persons
Alzheimer’s Disease living in an institution. The following personal partly with and without cognitive disabilities, people with
characteristic of people with dementia living in an institution was dementia that are female, people with Alzheimer’s Disease and
related to positive intervention effects: type of dementia. people with moderate to severe AD). The following personal
characteristics of people with dementia living in an institution
3.4.2.2. Cognitive problems (not otherwise specified). Nine studies were related to positive intervention effects: type and severity of
described interventions, namely Psychomotor Activation Pro- dementia, presence of behavioural problems, presence of mental
gramme (PAP) (Hopman-Rock et al., 1999), an individualized health problems, the composition of the intervention group, and
multidisciplinary programme (Holm et al., 1999), Alzheimer’s presence of ADL dependency.
rehabilitation by students (Arkin, 2003), skill elicitation (Rogers
et al., 1999), Life Review programme (Tabourne, 1995), snoezelen 3.4.3.2. Social behaviour. Fourteen studies described interventions,
(Holtkamp et al., 1997), Environmental barriers (Namazi and namely a life review programme (Tabourne, 1995), music therapy
Johnson, 1992b), reminiscence therapy (Namazi and Hayes, 1994) (Lord and Garner, 1993), a snoezel care plan (Van Weert et al.,
and closet modification (Namazi and Johnson, 1992a), that 2005), Psychomotor Activation Programme (PAP) (Hopman-Rock
succeeded in decreasing cognitive problems in subgroups of et al., 1999), animal-assisted therapy (Churchill et al., 1999),
people with dementia living in an institution (i.e. people with individually tailored multidisciplinary interventions (Opie et al.,
moderate to severe dementia, people with dementia and 2002), A.G.E. Dementia Care Program (Rovner et al., 1996),
behavioural problems, people with dementia and depression at structured movement and sensory stimulation (Arno and Frank,
baseline, people with dementia and bipolar disorders, people with 1994), Melissa aromatherapy (Ballard et al., 2001), reminiscence
dementia and high ADL dependency, people with dementia that therapy (Gibson, 1994; Head et al., 1990; Moss et al., 2002), a
are female, people with mild to moderate AD and people with resident dog (McCabe et al., 2002) and simulated presence
moderate to severe AD.) The following personal characteristics of therapy (Camberg et al., 1999), that succeeded in improving social
people with dementia living in an institution were related to behaviour in subgroups of people with dementia living in an
positive intervention effects: type and severity of dementia, institution (i.e. people with moderate to severe dementia, people
presence of depression, presence of behavioural problems and with severe to very severe dementia, people with dementia and
ADL dependency. behavioural problems, people with dementia and agitation,
women with primary degenerative dementia, people with
3.4.2.3. Speech problems. Three studies described interventions, dementia and agitated behaviour during evening hours and
namely a snoezel care plan (Van Weert et al., 2005), Alzheimer people with dementia and moderate to severe nursing depen-
rehabilitation by students (Arkin, 2003), and a resident dog dencies). The following personal characteristics of people with
(McCabe et al., 2002), that succeeded in decreasing speech dementia living in an institution were related to positive
problems in subgroups of people with dementia living in an intervention effects: type and severity of dementia, gender,
institution (i.e. people with moderate to severe dementia and presence of agitation, presence of behavioural problems and ADL
people with mild to moderate AD). The following personal dependency.
172
Table 2
Characteristics of people with dementia living in an institution related to effective intervention outcomes.

Institution-based care Type of dementia Dementia not specified

Patient characteristics Dementia Severity Behavioural problems Mental Health Problems Gender
Moderate Severe to Behavioural Agitation Aggression Disruptive Withdrawn Depression Bipolar Sleep Irregular Male Woman with
to severe very severe problems at pre- wandering behaviour at baseline disorders disorders sleep- gender primary
dementia dementia admission behaviour wake degenerative
rhythm dementia

Effects Intervention
Quality of life
Decreased discomfort Dementia special care
unit
Person-centered 48
showering
Towel bath 48
Sensory stimulation 83
activities
Decreased boredom Resident dog 38

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


More happy facial Simulated presence 25 25 25
expressions therapy
Improved interest 25 25 25
(affective reaction)
Increased affect Music during bathing

Cognitive functioning memory problems


Increased recall Music therapy

Cognitive functioning cognitive problems


Improved cognition Psychomotor 34
Activation Programme
(PAP)
Individualized, 31
multidisciplinary
program
Alzheimer
rehabilitation by
students
Reminiscence therapy
Increased functioning Skill elicitation
on ADL Individualized, 31 31 31
multidisciplinary
program
Decrease in disorientation Life review program 49
Improved awareness ‘‘Snoezelen’’ 33
Increased attention span Environmental barriers
Less visual and auditory
distractions
Increased ability to stay Life review program 49
engaged in activities
Improved learning abilities Alzheimer
Improvement on generic rehabilitation by
biographical knowledge students
Enhancement of score on
picture description task
Increased independence Closet modification
in dressing

Cognitive Functioning speech problems


Improved production of Snoezel care plan 50
normal length sentences
Increased use of Alzheimer
(different) nouns rehabilitation
by students
Decreased irrational Resident dog 38
behaviour

Behavioural functioning not otherwise specified


Decreased behavioural Sensory stimulation 33
disturbances (snoezelen)
Morning bright light 40 40
therapy
Daytime social 43 43 43
interaction with nurses
Special Care Units 24
Program
Special Care Units 23 23
(SCU)
A.G.E. Dementia 47
Care Program

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Expressive Physical 35
Touch with
Verbalization (EPT/V)
Behavioural 78 78
Management Program
Skill elicitation
Reminiscence therapy
71
Decreased behavioural Person-centered
problems during bathing showering
Increased cooperation Music during bathing
during bathing

Behavioural functioning social functioning


Improved social interaction Life review program 49
Music therapy
Improved socialization Snoezel care plan 50
behaviour Psychomotor 34
Activation Programme
(PAP)
Animal-assisted
therapy 69
Reminiscence therapy 71
Improved discourse patterns
Improved decorum Snoezel care plan 50
Decreased socially Individually Tailored 48 48
inappropriate behaviours multidisciplinary
Interventions
Resident dog 38
(Higher likelihood to) A.G.E. Dementia 47
participate in activities Care Program
Improved sense Structured movement 21
of group and sensory
cohesion stimulation
Improved responsiveness 21
Reduced withdrawn Melissa aromatherapy 22 22
behaviour Simulated presence 25 25
therapy

173
174
Table 2 (Continued )
Institution-based care Type of dementia Dementia not specified

Patient characteristics Dementia Severity Behavioural problems Mental Health Problems Gender
Moderate Severe to Behavioural Agitation Aggression Disruptive Withdrawn Depression Bipolar Sleep Irregular Male Woman with
to severe very severe problems at pre- wandering behaviour at baseline disorders disorders sleep- gender primary
dementia dementia admission behaviour wake degenerative
rhythm dementia

Behavioural Functioning
aggressive agitated
behaviour
Decreased aggression Snoezel care plan 50
Release from mandatory 39 39 39 39
indoor confinement
Resident dog 38
Individually tailored 44 44
multidisciplinary 31 31
interventions
Walking program 32 32

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Person-centered showering 48
Towel bath 48
Music during bathing
Natural elements intervention 82
during shower bath
Behavioural Management 78
Program
Reminiscence therapy 71
Decreased agitation Low intensity exercise/
movement Program
Individualized music 30 30
therapy
Classical ‘relaxation’ 30 30
music therapy
Individualized music 29 29
Bright light treatment 37 37 37
Simulated presence 25 25 25
therapy
Aromatherapy 22 22
Therapy dog
Person-centered 48
showering
Behavioural Management 78
Program
Towel bath 48
Natural elements 82
intervention during
shower bath
Recreational 86
interventions
(sensorimotor program)
Reminiscence therapy

Decreased restless Individually tailored 44 44


behaviour multidisciplinary
interventions
‘‘Snoezelen’’ 33
Reminiscence therapy
Decreased dangerous Resident dog 38
behaviours
Decreased rebellious Snoezel care plan 50
behaviour

Behavioural functioning repetitive behaviour


Decreased repetitive ‘‘Snoezelen’’ 33
behaviour
Decreased repetitive Individually Tailored 44 44
verbalizations multidisciplinary
Interventions
Decreased vocalizations Music therapy
(classic and favorite)
Decreased fidgeting Sensory stimulation 83
activities

Mental health
Improved mood Snoezel care plan 50
Music therapy
Reminiscence therapy
Decreased depression Individualized 46
multicomponent treatment

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


programme
Snoezel care plan 50
Alzheimer rehabilitation
by students
Decreased apathy Sensory stimulation 33 and 50
(snoezelen)/snoezel
care plan
Decreased anxiety Expressive Physical Touch 35
with Verbalization (EPT/V)
Decreased Individualized 46
psychopathological multicomponent
symptoms treatment programme
Decreased Special Care Units (SCU) 23 23
psychotropics use
Decreased use A.G.E. Dementia Care 47
of antipsychotics Program
Release from mandatory
indoor confinement
Increased use Individualized, 31
of antipsychotic, multidisciplinary program
antidepressant and
mood-stabilizing
agents
Decrease in antianxiety 31
agents
Increased cheerfulness Reminiscence therapy
during therapy sessions

Physical health
Improved physical health Alzheimer rehabilitation
Increased strength by students
Regular exercise
Recreational interventions 86
Increased flexibility (sensorimotor program)
Increased sleep time Morning bright light therapy 40 40
Improved sleep behaviour Resident dog 38
Decreased sleep-wake Daytime social 43 43 43
rhythm disorders interaction with nurses
Increased nutritional Animal-assisted therapy
intake Nutritional program 76
Increased appetite Reminiscence therapy

175
176
Table 2 (Continued )
Institution-based care Type of dementia Dementia not specified

Patient characteristics Dementia Severity Behavioural problems Mental Health Problems Gender
Moderate Severe to Behavioural Agitation Aggression Disruptive Withdrawn Depression Bipolar Sleep Irregular Male Woman with
to severe very severe problems at pre- wandering behaviour at baseline disorders disorders sleep- gender primary
dementia dementia admission behaviour wake degenerative
rhythm dementia

Improved skin condition Person-centered 48


showering
Towel bath 48
Improved debris scores Person-centered 48
showering
Towel bath 48

Other positive outcomes


Decreased use of Special Care Units (SCU) 23 23
physical restraints A.G.E. Dementia Care 47
Program

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Lower mortality risk Dementia Special Care
Lower medication costs Unit

Institution-based care Type of dementia Dementia not specified Alzheimer’s Disease

Patient characteristics Other specific characteristics Severity Behavioural Gender Other


problems

High Agitated Moderate Aggression Mixed Admittance Alzheimer’s Mild to Moderate severe Repetitive Female Discharge Aggression Chair-
ADL behaviour to severe during intervention from nursing Disease moderate to severe to very disruptive gender to psycho- during bound
depen- during nursing bathing groups: home AD AD severe vocalizations geriatric bathing
dency evening depen- with/ environment dementia unit
hours dencies without
cognitive
disabilities

Effects Intervention
Quality of life
Decreased discomfort Dementia special care unit 51
Person-centered showering 48
Towel bath 48
Sensory stimulation activities
Decreased boredom Resident dog
More happy facial Simulated presence therapy
expressions
Improved interest
(affective reaction)
Increased affect Music during bathing 80 80

Cognitive functioning memory problems


Increased recall Music therapy 36

Cognitive functioning cognitive problems


Improved cognition Psychomotor Activation
Programme (PAP)
Individualized,
multidisciplinary program
Alzheimer rehabilitation 20
by students
Reminiscence therapy 72 72
Increased functioning Skill elicitation 45 45
on ADL Individualized,
multidisciplinary program
Decrease in disorientation Life review program
Improved awareness ‘‘Snoezelen’’
Increased attention span Environmental barriers 85
Less visual and auditory
distractions
Increased ability to stay Life review program
engaged in activities
Improved learning abilities Alzheimer rehabilitation 20
Improvement on generic by students 20
biographical knowledge
Enhancement of score 20
on picture description
task
Increased independence Closet modification 41
in dressing

Cognitive functioning
speech problems
Improved production of Snoezel care plan
normal length sentences
Increased use of Alzheimer rehabilitation 20

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


(different) nouns by students
Decreased irrational Resident dog
behaviour

Behavioural functioning
not otherwise specified
Decreased behavioural Sensory stimulation
disturbances (snoezelen)
Morning bright light 40
therapy
Daytime social interaction 43 43
with nurses
Special Care Units Program
Special Care Units (SCU)
A.G.E. Dementia Care Program
Expressive Physical Touch
with Verbalization (EPT/V)
Behavioural Management
Program
Skill elicitation 45 45
Reminiscence therapy 70

Decreased behavioural Person-centered showering 48


problems during bathing
Increased cooperation Music during bathing 80 80
during bathing

Behavioural functioning
social functioning
Improved social interaction Life review program
Music therapy 36
Improved socialization Snoezel care plan
behaviour Psychomotor Activation
Programme (PAP)
Animal-assisted therapy 27
Reminiscence therapy

Improved discourse 79
patterns
Improved decorum Snoezel care plan 50
Decreased socially Individually tailored
inappropriate behaviours multidisciplinary
Interventions

177
Resident dog
178
Table 2 (Continued )
Institution-based care Type of dementia Dementia not specified Alzheimer’s Disease

Patient characteristics Other specific characteristics Severity Behavioural Gender Other


problems

High Agitated Moderate Aggression Mixed Admittance Alzheimer’s Mild to Moderate severe Repetitive Female Discharge Aggression Chair-
ADL behaviour to severe during intervention from nursing Disease moderate to severe to very disruptive gender to psycho- during bound
depen- during nursing bathing groups: home AD AD severe vocalizations geriatric bathing
dency evening depen- with/ environment dementia unit
hours dencies without
cognitive
disabilities

(Higher likelihood to) A.G.E. Dementia Care


participate in activities Program
Improved sense of group Structured movement and
cohesion sensory stimulation
Improved responsiveness
Reduced withdrawn Melissa aromatherapy
behaviour Simulated presence therapy

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Behavioural functioning aggressive agitated behaviour
Decreased aggression Snoezel care plan
Release from mandatory 39
indoor confinement
Resident dog
Individually tailored
multidisciplinary 31
interventions
Walking program
Person-centered showering 48
Towel bath 48
Music during bathing 80 80
Natural elements
intervention during
shower bath
Behavioural Management
Program
Reminiscence therapy
Decreased agitation Low intensity exercise/ 42
movement Program
Individualized music
therapy
Classical ‘relaxation’
music therapy
Individualized music
Bright light treatment
Simulated presence
therapy
Aromatherapy
Therapy dog 27
Person-centered 48
showering
Behavioural Management
Program
Towel bath 48
Natural elements
intervention
during shower bath
Recreational interventions
(sensorimotor program)
Reminiscence therapy 70
71 71
Decreased restless Individually tailored
behaviour multidisciplinary
interventions
‘‘Snoezelen’’
Reminiscence therapy 70
Decreased dangerous Resident dog
behaviours
Decreased rebellious Snoezel care plan
behaviour

Behavioural functioning repetitive behaviour


Decreased repetitive ‘‘Snoezelen’’
behaviour
Decreased repetitive Individually tailored
verbalizations multidisciplinary
Interventions
Decreased vocalizations Music therapy (classic 26
and favorite)
Decreased fidgeting Sensory stimulation
activities
Mental health

L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183


Improved mood Snoezel care plan
Music therapy 36
Reminiscence therapy 72 72
Decreased depression Individualized
multicomponent
treatment programme
Snoezel care plan 50
Alzheimer rehabilitation 20
by students
Decreased apathy Sensory stimulation
(snoezelen)/snoezel
care plan
Decreased anxiety Expressive Physical
Touch with
Verbalization (EPT/V)
Decreased Individualized
psychopathological multicomponent
symptoms treatment programme
Decreased Special Care Units (SCU)
psychotropics use
Decreased use of A.G.E. Dementia Care
antipsychotics Program
Release from mandatory 39
indoor confinement
Increased use of Individualized,
antipsychotic, multidisciplinary program
antidepressant and
mood-stabilizing agents
Decrease in antianxiety
agents
Increased cheerfulness Reminiscence therapy 70
during therapy sessions

Physical health
Improved physical health Alzheimer rehabilitation 20
Increased strength by students
Regular exercise 81 81
Recreational interventions
Increased flexibility (sensorimotor program)
Increased sleep time Morning bright light 40
therapy
Improved sleep behaviour Resident dog
Decreased sleep-wake Daytime social interaction 43

179
rhythm disorders with nurses
180 L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183

3.4.3.3. Aggressive, agitated behaviour. Twenty-one studies

bound
Female Discharge Aggression Chair-
described interventions, namely a snoezel care plan (Van Weert
et al., 2005), release from mandatory indoor confinement (McMinn
and Hinton, 2000), a resident dog (McCabe et al., 2002),
bathing
gender to psycho- during
individually tailored multidisciplinary interventions (Holm et al.,
1999; Opie et al., 2002), a walking programme (Holmberg, 1997),
person-centred showering and the towel bath (Sloane et al., 2004),
geriatric

Behavior Management Program (DeYoung et al., 2002), low


Gender Other

unit

intensity exercise/movement programme (Namazi et al., 1994),


individualized music therapy and classical ‘relaxation’ music
therapy (Gerdner and Swanson, 1993), individualized music
(Gerdner, 2000), music during bathing (Clark et al., 1998), Natural
vocalizations

elements intervention during shower bath (Whall et al., 1997),


Behavioural

disruptive
Repetitive
problems

bright light treatment (Lovell et al., 1995), simulated presence


therapy (Camberg et al., 1999), Melissa aromatherapy (Ballard
et al., 2001), reminiscence therapy (Gibson, 1994), Recreational
dementia

interventions (sensorimotor programme) (Buettner et al., 1996), a


to very
severe

severe

therapy dog (Churchill et al., 1999), and snoezelen (Holtkamp et al.,

51
51
1997), that succeeded in reducing aggressive, agitated behaviour in
Moderate
moderate to severe

subgroups of people with dementia living in an institution (i.e.


people with moderate to severe dementia, people with severe to
AD

very severe dementia, people with dementia and behavioural


problems, people with dementia and agitation, people with
Severity

Alzheimer’s Mild to
Alzheimer’s Disease

dementia and aggression at pre-admission, people with dementia


AD

and disruptive wandering behaviour, people with dementia and


withdrawn behaviour, people with dementia and depression at
baseline, people with dementia and bipolar disorders, people with
intervention from nursing Disease

dementia who are male, people with dementia and agitated


28

behaviour during evening hours, people with dementia and


environment

aggression during bathing people with dementia participating in


Admittance

mixed intervention groups of persons partly with and without


home

cognitive disabilities, people with dementia who were admitted


from a nursing home environment, people with Alzheimer’s
Disease, people with AD and aggression during bathing and people
disabilities
cognitive
without

with AD who were discharged from a psychogeriatric unit). The


groups:
Moderate Aggression Mixed

with/

following personal characteristics of people with dementia living


70

in an institution were related to positive intervention effects: type


and severity of dementia, gender, presence of depression, presence
bathing
to severe during

of agitation, presence of (other) behavioural problems, presence of


48

48
48

48

mental health problems, the composition of the intervention


group, and discharge outcome.
Other specific characteristics

nursing

dencies
depen-

3.4.3.4. Repetitive behaviour. Four studies described interventions,


Dementia not specified

namely snoezelen (Holtkamp et al., 1997), individually tailored


behaviour
Agitated

evening

multidisciplinary interventions (Opie et al., 2002), sensory


during

hours

stimulation activities (Witucki and Twibell, 1997), and music


therapy (Casby and Holm, 1994), that succeeded in decreasing
depen-
dency

repetitive behaviour in subgroups of people with dementia living


High
ADL

in an institution (i.e. people with moderate to severe dementia,


people with severe to very severe dementia, people with dementia
and behavioural problems, people with AD and repetitive
Special Care Units (SCU)
Animal-assisted therapy

Dementia Special Care

disruptive vocalizations). The following personal characteristics


Patient characteristics

Reminiscence therapy

A.G.E. Dementia Care


Nutritional program

of people with dementia living in an institution were related to


Type of dementia

Person-centered

Person-centered

positive intervention effects: type and severity of dementia and


presence of behavioural problems.
Towel bath

Towel bath
showering

showering

Program

Unit

3.4.4. Mental health


Twelve described interventions, namely a snoezel care plan
(Van Weert et al., 2005), music therapy (Lord and Garner, 1993),
Improved skin condition

Lower medication costs


Improved debris scores

Other positive outcomes

individualized multicomponent treatment programme (Romero


Institution-based care

Increased nutritional

Lower mortality risk


physical restraints
Table 2 (Continued )

and Wenz, 2001), Alzheimer rehabilitation by students (Arkin,


Increased appetite

Decreased use of

2003), sensory stimulation (Holtkamp et al., 1997), reminiscence


therapy (Gibson, 1994), Expressive Physical Touch with Verbaliza-
intake

tion (EPT/V) (Kim and Buschmann, 1999), Special Care Units (SCU)
(Bellelli et al., 1998), A.G.E. Dementia Care Program (Rovner et al.,
1996), release from mandatory indoor confinement (McMinn and
L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183 181

Hinton, 2000), sensory stimulation (Witucki and Twibell, 1997), interventions. For people with dementia, regardless of whether
and an individualized multidisciplinary programme (Holm et al., they are living in the community or in an institution, character-
1999), that succeeded in improving mental health in subgroups of istics such as type and severity of dementia, gender, and the
people with dementia living in an institution (i.e. people with presence of behavioural problems or mental health problems
moderate to severe dementia, people with severe to very severe proved related to positive intervention outcomes, such as
dementia, people with dementia and behavioural problems, people decreased depression or decreased behavioural problems. Accord-
with dementia and moderate to severe nursing dependencies, ing to Smits et al. (2007) attention needs to be paid to the different
people with dementia participating in mixed intervention groups needs of subgroups of people with dementia. Dementia care should
of persons partly with and without cognitive disabilities, people focus on the diversity of needs of different target groups (for
with Alzheimer’s Disease, people with mild to moderate AD and instance, depressed persons with dementia (Smits et al., 2007)) for
people with AD that were discharged from a psychogeriatric unit). whom programmes may be most effective, in order to be able to
The following personal characteristics of people with dementia supply demand-directed care more efficiently and effectively.
living in an institution were related to positive intervention Characteristics that were frequently found to be related to
effects: type and severity of dementia, presence of behavioural positive intervention effects for people with dementia living in the
problems, composition of the intervention group, and discharge community are: type and severity of dementia and their living
outcome. situation. Characteristics that only few studies showed to be linked
with effective intervention outcomes are gender, presence of
3.4.5. Physical functioning depression, agitation, or behavioural problems, and whether or not
Ten studies described interventions, namely Alzheimer reha- people with dementia living in the community are currently using
bilitation by students (Arkin, 2003), morning bright light therapy care. For people with dementia living in an institution, type and
(Mishima et al., 1994), a resident dog (McCabe et al., 2002), severity of dementia, gender, presence of behavioural problems
daytime social interaction with nurses (Okawa et al., 1991), and presence of mental health problems, were often described to
reminiscence therapy (Gibson, 1994), animal-assisted therapy characterize the sample under study. Only a limited number of
(Edwards and Beck, 2002), a nutritional programme (Biernacki and studies, however, found characteristics such as depression,
Barrat, 2001), Recreational interventions (sensorimotor pro- agitation and aggression and ADL dependency, to be related to
gramme) (Buettner et al., 1996), regular exercise (Francese positive intervention outcomes.
et al., 1997) and person-centred showering or towel bath (Sloane Overall, in this review we were able to provide a relatively new
et al., 2004), that succeeded in improving physical health in and unique overview of the characteristics of people with
subgroups of people with dementia living in an institution (i.e. dementia that are related to effective intervention outcomes.
people with moderate to severe dementia, people with severe to Based on this knowledge, healthcare professionals will be better
very severe dementia, people with dementia and behavioural able to refer patients with specific characteristics to suitable
problems, people with dementia and sleep problems, people with interventions that are expected to be effective for them. Our results
dementia and irregular sleep-wake rhythms, people with demen- can be used in different ways. On the one hand, professionals can
tia and aggression during bathing, people with dementia start with an unmet need of a person with dementia and search for
participating in mixed intervention groups of persons partly with a linked intervention, and also find whether there is a specific
and without cognitive disabilities, people with Alzheimer’s characteristic that will increase the likelihood of success of that
Disease, people with mild to moderate AD and people with particular intervention. Or they can refer a person with dementia
moderate to severe AD). The following personal characteristics of from a specific subgroup, experiencing for instance mental health
people with dementia living in an institution were related to problems, to an intervention that is most likely to be effective. On
positive intervention effects: type and severity of dementia, the other hand, healthcare professionals that practice a certain
presence of behavioural problems, composition of the intervention intervention can use our table to identify specific subgroups of
group, and presence of mental health problems. people that could benefit in particular from that intervention.
There were several limitations to our research. Some of the studies
3.4.6. Other positive outcomes described more than one characteristic of persons that in
Three studies described interventions, namely Special Care combination were related to effective outcomes (Holm et al.,
Units (SCU) (Bellelli et al., 1998), A.G.E. Dementia Care Program 1999; Camberg et al., 1999). In these cases each characteristic was
(Rovner et al., 1996) and the Dementia Special Care Unit (Volicer considered independently related to the effective intervention
et al., 1994), that improved other positive outcomes (i.e. outcome(s). Within the time frame of our study it was impossible
‘‘decreased use of physical restraints’’, ‘‘lower mortality risk’’, to further investigate whether any of these characteristics
‘‘lower medication costs’’) in subgroups of people with dementia independently lead to a positive outcome on the interventions
living in an institution (i.e. people with severe to very severe in question.
dementia, people with dementia and behavioural problems and Although some studies found specific effects for certain
people with severe to very severe AD). The following personal subgroups of people with dementia or carers (Bourgeois, 1990;
characteristics of people with dementia living in an institution McCabe et al., 2002), many studies used a homogeneous sample of
were related to positive intervention effects: type and severity of participants. This led to, for instance, a positive intervention
dementia and presence of behavioural problems. outcome for people with Alzheimer’s disease, when it was not clear
what the effects would be for people with a different type of
4. Conclusion and discussion dementia.
Although this overview is already very helpful for professionals
In this study we tried to gain more insight into the in dementia care, the results of this study also mean that more
characteristics of people with dementia that may predict positive research should be conducted into characteristics that have not
effects of individual care and welfare interventions. We traced 76 been studied to date, such as education, loneliness, ethnic
studies that reported on the effectiveness of care and welfare background, and socio-economic status. Also, combinations of
interventions within subgroups of people with dementia. characteristics should be investigated, as well as those character-
We found different personal contextual characteristics of istics of subgroups of people with dementia that were not yet
people with dementia to be related to positive outcomes of included in outcome studies. We noticed, for instance, that many
182 L.D. Van Mierlo et al. / Ageing Research Reviews 9 (2010) 163–183

studies reported positive effects on cognitive functions in the 24 Bianchetti, A., Benvenuti, P., Ghisla, K.M., Frisoni, G.B., Trabucchi, M., 1997. An
Italian model of dementia special care unit: results of a pilot study. Alzheimer
subgroup of people with AD living at home, but relatively few Dis. Assoc. Disord. 11, 53–56.
studies reported positive effects on physical health in this same 76 Biernacki, C., Barrat, J., 2001. Improving the nutritional status of people with
group. Further studies need to be conducted to gain insight into the dementia. Br. J. Nurs. 10, 1104–1114.
2 Bourgeois, M.S., 1990. Enhancing conversation skills in patients with Alzheimer’s
effects of different psychosocial interventions in subgroups of disease using a prosthetic memory aid. J. Appl. Behav. Anal. 23, 29–42.
people with dementia. 3 Bourgeois, M.S., Burgio, L.D., Schulz, E., Beach, S., Palmer, B., 1997. Modifying
We found that home-based studies focused on people with repetitive verbalizations of community-dwelling patients with AD. Gerontol-
ogist 37, 30–39.
dementia with Alzheimer’s Disease and dementia (not otherwise 4 Brodaty, H., Gresham, M., Luscombe, G., 1997. The Prince Henry Hospital dementia
specified), in particular on mild to moderate dementia, and reported caregivers’ training programme. Int. J. Geriatr. Psychiatry 12, 183–192.
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