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O'Neil ME, Freeman M, Christensen V, et al. A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms of Dementia [Internet]. Washington (DC): Department of Veterans Affairs (US); 2011 Mar.

Cover of A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms of Dementia

A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms of Dementia [Internet].

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METHODS

TOPIC DEVELOPMENT

The review was requested by the VHA Dementia Steering Committee (DSC) and commissioned by the Department of Veterans Affairs' Evidence-based Synthesis Program. The DSC served as the technical expert panel for guiding topic development and reviewing drafts of the report. The objective of this report is to review the evidence that addresses the following questions:

  • Key Question #1. How do non-pharmacological treatments of behavioral symptoms compare in effectiveness with each other, with pharmacological approaches, and with no treatment?
  • Key Question #2. How do non-pharmacological treatments of behavioral symptoms compare in safety with each other, with pharmacological approaches, and with no treatment?
  • Key Question #3. How do non-pharmacological treatments of behavioral symptoms compare in cost with each other, with pharmacological approaches, and with no treatment?

Population: Adults with mild, moderate, or severe dementia.

Behavioral symptoms: Apathy, agitation, disruptive vocalizations, aggression, disturbed sleep, wandering, impulsivity, disinhibition, depression, inappropriate sexual behavior, chronic/ intermittent hallucinations and delusions.

Interventions: Non-pharmacological treatments include cognitive/emotion-oriented interventions (e.g., reminiscence therapy, simulated presence therapy, and validation therapy), sensory stimulation interventions (e.g., acupuncture, aromatherapy, light therapy, massage/touch therapy, music therapy, Snoezelen multisensory stimulation, and Transcutaneous Electrical Nerve Stimulation (TENS)), behavior management techniques, other psychosocial interventions (e.g., animal-assisted therapy and exercise), and various interventions targeting a specific behavioral symptom (e.g., wandering, agitation, and inappropriate sexual behavior).

Comparators: Routine care; medical (e.g., ECT)/pharmacological treatment (e.g., typical and atypical antipsychotics, benzodiazepines and their pharmacological relatives, cholinesterase inhibitors, mood stabilizers, anti-depressants, N-Methyl-D-aspartic acid receptor antagonists); other non-pharmacological treatment; or no treatment.

Outcomes: Use of psychotropic drugs; cognition; mood, behavioral symptoms; social function, or physical function; hospitalizations, institutionalizations, or healthcare visits including ER visits; accidents, such as accidental falls or automobile crashes; mortality; health-related quality of life; and satisfaction with healthcare.

Setting: All outpatient care settings including home-based care and ambulatory care, and extended-care facility settings. Treatments for acute psychotic episodes are excluded.

SEARCH STRATEGY

We conducted searches for systematic reviews of non-pharmacological interventions for dementia in MEDLINE (PubMed), the Cochrane Database of Systematic Reviews, the Cochrane Database of Reviews of Effects (OVID), and PsycInfo from database inception through September 2009 (Appendix A). We obtained additional articles from reference lists of pertinent studies. Additional articles were obtained through reviewer feedback following review of the initial draft of this report. All citations were imported into an electronic database (EndNote X2).

Because the initial search identified no systematic reviews on animal-assisted therapy, we proceeded to conduct a search for primary studies (Appendix B).

STUDY SELECTION AND QUALITY ASSESSMENT

We included good quality systematic reviews of non-pharmacological interventions in individuals with dementia, but excluded interventions that targeted primarily caregiver outcomes as we had conducted a separate review of this topic.8 Two reviewers assessed the titles and abstracts identified by the literature search for relevance to the key questions. Potentially relevant full-text articles were retrieved for further review. Each article was reviewed using the eligibility criteria for systematic reviews shown in Appendix C. The quality rating of systematic reviews (see criteria, Appendix D) is based on the comprehensiveness and reproducibility of the search strategy, the use of standard methods to appraise the validity of included studies, and the absence of apparent bias in drawing conclusions. Because technological interventions such as GPS tracking devices are recent innovations and not widely studied, we allowed inclusion of fair quality reviews of these technologies.

We conducted a search for primary studies of the effects of animal-assisted therapy on behavioral symptoms (inclusion criteria Appendix E), as no systematic reviews were available. We did not limit by study design, other than excluding case series and case reports, and rather than report a summary quality score, we noted limitations of individual studies.

DATA SYNTHESIS

We organized the literature into the following categories:

  • Cognitive/emotion-oriented interventions

    Reminiscence therapy

    Simulated presence therapy

    Validation therapy

  • Sensory stimulation interventions

    Acupuncture

    Aromatherapy

    Light therapy

    Massage/touch

    Music therapy

    Snoezelen multisensory stimulation

    TENS

  • Behavior management techniques (BMT)
  • Other psychosocial interventions

    Animal-assisted therapy

    Exercise

  • Various interventions targeting a specific behavioral symptom

    Wandering

    Agitation

We compiled a qualitative synthesis of the evidence on specific forms of therapy, and on various therapies targeting wandering and wandering behaviors. Given the breadth and complexity of studies on behavior management techniques, as well as stakeholder interest, we examined randomized controlled trials (RCTs) with sample size > 30 that were identified in previous systematic reviews, and additional studies of behavior management techniques that were referred to us by peer reviewers. Additionally, based on reviewer feedback, we included one primary study on agitation which was not captured in the review due to its recency.

We assessed the overall quality of evidence for outcomes using a method developed by the GRADE Working Group.9 The GRADE method considers the consistency, coherence, and applicability of a body of evidence, as well as the internal validity of individual studies to classify the grade of evidence across outcomes. The grade of evidence is rated as high, moderate, low, or very low, based on the confidence in the estimate of effect and the likelihood that future research would have an important impact on the certainty, magnitude, or direction of the estimate.

A list of abbreviations and their definitions is provided in Appendix F.

PEER REVIEW

A draft version of this report was sent to the technical advisory panel and additional peer reviewers. Their comments and our responses are included in Appendix G.

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