Nonpharmacological interventions administered in a home setting can significantly lower the severity and frequency of behavioral and psychological symptoms in patients with dementia, an Australian research suggests.
In addition, the meta-analysis showed that the interventions also improved reactions by the caregivers to these often stress-inducing symptoms.
“Behavioral and psychological symptoms occur in over 90% of people with dementia at some time during the course of their illness, [which] are very distressing for caregivers and the persons with dementia themselves,” lead author Henry Brodaty, DSc, professor of aging and mental health and director of the Dementia Collaborative Research Center at the University of New South Wales in Sydney, Australia, and director of aged care psychiatry at Prince of Wales Hospital, told Medscape Medical News.
Dr. Brodaty said that because medications that treat these symptoms “have limited efficacy,” as well as a significant potential for adverse events, the investigators were interested in assessing non-pharmacological alternatives.
“I found that the interventions administered by caregivers were at least as effective as drug treatments, but without the side effects,” he said.
“Clinicians should establish partnerships with caregivers and find ways of empowering them to be the ‘therapist’ for the person with dementia by learning skills and receiving counseling”, is a statement made by Dr. Brodaty I often echo, says Dr. Cathleen V. Carr, Executive Director of CertifiedCare.org. This philosophy and evidence based position is the cornerstone of our caregiver education and training programs.
Examples of common behavioral and neuropsychiatric symptoms of dementia include physical aggression, screaming, depression, wandering away from the home, suspiciousness, accusations, not accepting help with dressing or washing, and nighttime sleep problems.
“Behavioral and psychological symptoms rather than cognitive dysfunction, physical dependence, or functional impairment have been found to impose the greatest burden on family caregivers and to predict caregiver decisions to institutionalize persons with dementia,” write the investigators.
Although past research has shown that psychosocial therapies can be effective for treating dementia symptoms while a patient is in an institutional setting, finding effective methods for treating these symptoms in a home environment “is both a public health and an economic priority,” they add.
For this meta-analysis, the researchers assessed 16 randomized studies and 7 pseudo-randomized studies that evaluated non-pharmacological family caregiver interventions for treating these symptoms. All were conducted during the past 2 decades.
Some of the measurements used to rate symptom severity and/or frequency included the Revised Memory and Behavior Problem Checklist, the Behavioral Pathology in Alzheimer’s Disease Rating Scale, and the Neuropsychiatry Inventory. Caregiver reactions to the symptoms were also evaluated.
Some of the elements comprised within the interventions included the following:
- Skills training and education for caregivers
- Activity planning and modifying the patient’s environment
- Enhancing caregiver support through education, groups, telephone calls, and family counseling
- Self-care techniques for caregivers, including stress management and music therapy
- Collaborative care with a healthcare professional, and/or
- Exercise programs for the patient
The duration of the various interventions ranged from 6 weeks to 24 months.
Symptoms and Stress Reduced
Overall results showed that the caregiver interventions significantly reduced behavioral and psychological symptoms in the patients with dementia (P < .01).
Adverse reactions by caregivers to the symptoms were also significantly lowered after the interventions were administered (P = .006).
Specifically, 19 studies reported positive findings for the interventions on all symptom outcomes, and 3 showed neutral findings.
“The three studies with no treatment effects on symptoms still had other positive outcomes for caregivers, namely, a reduction in caregiver depressive symptoms, a decrease in caregiver burden, and an increase in caregiver general well-being,” report the investigators.
Although 1 study did report negative findings, neither it nor any of the others reported any treatment-related adverse effects. In addition, the negative study found similar decreases in behavioral symptoms in both the treatment group and the control group.
“Fine-grained questions regarding which elements of interventions are effective for which behavioral and psychological symptoms of dementia…require further attention,” write the researchers.
Still, they note that the most successful interventions appeared to include 9 to 12 tailored sessions administered in the home during a 3- to 6-month period and included telephone sessions and follow-ups. Aggression, depression, repetitive behaviors, and disruption were the behaviors most likely to respond to these types of interventions.
“For policy makers, our findings suggest that supporting programs to work with caregivers would be an efficient and potentially sustainable model,” write the investigators.
“For clinicians, caregivers, and persons with dementia, there is a preference for trying nonpharmacological approaches first and avoiding or delaying the use of medications,” they add.
This meta-analysis “provides strong evidence that helping families is good news for dementia care,” Laura N. Gitlin, PhD, from the Department of Psychiatry and Division of Geriatrics/Gerontology in the School of Medicine and from the Center for Innovative Care in Aging, both at Johns Hopkins University in Baltimore, Maryland, writes in an accompanying editorial.
“Given the number of patients and family members affected by dementia, the pervasiveness of behavioral symptoms, and their poor prognosis, behavioral management should be a clinical priority,” writes Dr. Gitlin.
However, she adds that there is currently no systematic, agreed-upon approach for doing this.
Although antipsychotic medications are commonly given to treat these symptoms in a clinical setting, Dr. Gitlin notes that guidelines from “numerous medical organizations,” including the American Psychiatric Association, recommend non-pharmacological alternatives, which may include those that incorporate caregiver support.
She adds that in Dr. Brodaty’s study, “a robust corpus of research” showed that psychosocial and environmental interventions involving family caregivers are effective.
“Yet, this body of strong evidence has been largely ignored by the medical community.”
Although the treatment effects found in this analysis “were small to medium,” Dr. Gitlin notes that they are still clinically meaningful.
“Even small changes in behaviors can help families to keep a relative with dementia living at home longer with improved quality of life,” she writes.
She also agrees with the investigators that more research is needed, especially to determine implementation considerations.
“How is a clinician to choose which intervention to invest in and learn to use? At this stage of the evidence and until clarity, decision rules, and more precision are achieved, it may be preferable to consider all of these interventions as part of a tool kit,” writes Dr. Gitlin.
The study is published in the 2012 September issue of the American Journal of Psychiatry.
Financial disclaimer: Dr. Brodaty reports having served as an advisory board member, consultant, or speaker for Baxter, Janssen, Lilly, Lundbeck, Merck, Novartis, and Pfizer; and having received travel support and/or research grants from Janssen, Pfizer, Medivation, and Sanofi. The other study author has disclosed no relevant financial relationships. Dr. Gitlin reports receiving funding from the Alzheimer’s Association.