Nonpharmacological Management of Dementia: A Review

INTRODUCTION

There are 50 million suffering from dementia and India houses the second most number of them with an estimated 4.1 million people as per the “Dementia India” report published by the Alzheimer’s and Related Disorders Society of India. This is expected to double by 2035.¹ The onset of dementia is usually seen in 60s and increases when individual reaches in the octogenarian age. Dementia, a common and neuropsychiatric syndrome, in itself is not a specific disease/disorder. It refers to a group of symptoms caused by brain disorders.² It is a progressive condition that affects the abilities to think, solve problems, or control emotions that brings about cognitive and personality changes with functional decline.³ Dementia may also lead to progressive memory loss. Activities of daily living (ADLs) are progressively impaired in dementia.⁴ Biological functions such as sleep and appetite are usually affected by dementia, as are neuromuscular functions such as gait and balance.⁵

Though nonpharmacological treatment (NPT) is the first line of treatment for dementia, by choice, treatment has persisted to remain pharmacological in approach. Reasons such as less investment in cost of human labor and time and quicker administration of medication have served a win over nonpharmacological management.⁶ The development of new drugs and their availability has received considerable attention from the media, the public, professionals, and family caregivers as well as from persons with dementia.⁷ However, for over a decade, research has favored the nonpharmacological interventions for management of dementia as the first line of treatment as they have been scientifically addressed and evidence of their effectiveness has been systematized.⁸

NONPHARMACOLOGICAL MANAGEMENT OF DEMENTIA

In an ideal scenario, dementia should be diagnosed followed by postdiagnostic counseling to provide support with coming to terms with the diagnosis. The aim of rehabilitation in dementia is to improve functioning of the individual through a holistic approach that involves psychosocial, cognitive, physical, and sensory components.⁹ These strategies may be implemented in a variety of settings and treatment modalities. A range of psychosocial interventions that are flexible should be developed to match the needs of the patient and the caregiver.

Cognitive problems have been the traditional focus of interest in research and management for people with dementia.¹⁰ However, present research findings have revealed a number of commonly seen noncognitive symptoms (it is important to note that there is an ongoing debate regarding the basic terminology for “noncognitive” symptoms. The term currently favored in the psychiatric literature is “behavioral and psychological symptoms of dementia,” but most of the psychology community still uses the label “challenging behavior.” Researchers have distinguished between behavioral excesses and behavioral deficits)¹¹ that are problematic not only for the person but also for their caregivers; thus, they are relevant in relation to clinical management. The noncognitive symptoms include agitation, aggression, mood disorders and psychosis, sexual disinhibition, eating problems, and abnormal vocalizations.¹² The International Psychogeriatric Association grouped these symptoms together under an umbrella term “behavioral and psychological symptoms of dementia,” abbreviated as BPSD.¹³ Behavioral and psychological symptoms of dementia are usually transient and often respond to simple changes in the environment or removal of aggravating factors. Behavioral and psychological symptoms of dementia involves pharmacological and nonpharmacological interventions, though a sound clinical background must identify the root cause of BPSD.¹⁴

The concerning switch from pharmacological to nonpharmacological management was born out of documented research, which outlined the substantial adverse effects like sedation, falls, extrapyramidal signs, and possibility of reduction in quality of life and possible accelerating cognitive decline in the patients.¹⁵ Though there exists no direct comparison to evidence the comparative use of pharmacological and NPT methods, the latter has shown to be beneficial in managing behavioral and psychological symptoms related to dementia.¹⁶ It has been reported that psychosocial interventions work best to reduce agitation and to improve other behavioral disturbances in people with dementia when they are personalized to reflect the individual’s background and environmental circumstances.¹⁷

According to Cohen-Mansfield, most professionals have some training in medication prescription for BPSD but are not appropriately instructed about nonpharmacological interventions or receive information about their effectiveness. As a consequence, antipsychotics drugs are frequently prescribed before alternative nonpharmacological approaches are attempted, and patients are maintained in medication for long periods, which leads to increasing morbidity and mortality. Fewer side effects have been associated with NPTs, which render them as safer line of treatment.¹⁸

Nonpharmacological treatments entail a broad spectrum of approaches that involve to work with the patient and/or their caregivers, physical, and social environments—entailing psychological, psychosocial, interpersonal, behavioral, emotional, exercise, and environmental interventions.¹⁹ The NPTs can be broadly categorized as generalized (behavior nonspecific) or targeted (behavior-specific) treatments. These approaches either directly involve the patients and/or work through another agent—usually, the care provider or physical environment.²⁰ These approaches conceptualize behavioral symptoms in three ways viz. the following:²¹

• As expressions of unmet needs (e.g., repetitive vocalizations for auditory stimulation).
• Inadvertently reinforced behavior in response to environmental triggers (e.g., patient learns screaming attracts increased attention).
• Consequences of a mismatch between the environment and patients’ abilities to process and act upon cues, expectations, and demands.

These approaches generally work to modify patient and/or caregiver cognition styles, behavior patterns, environments, precipitating events, or instructing in compensatory strategy use—to reduce the risk/vulnerability of the patients and to their environment. It is widely accepted that the care environment (physical and social) and day-to-day interactions between caregivers and persons with dementia can have a considerable impact. This means that virtually all dementia care has the potential to be therapeutic.²²

Nonpharmacological alternatives encompass psychotherapy, psychoeducation, and self-care. Within that, it includes a wide range of therapies such as behavior therapy, reality orientation, music therapy, validation, and the potential of interesting new alternative options such as cognitive therapy, aromatherapy, and multisensory therapies. It is crucial to know that no one therapy is used in isolation but there are several overlaps between the therapies, and thus, an eclectic approach is the best to use.²³

GOALS OF NONPHARMACOLOGICAL TREATMENTS

It is crucial to consider that though NPTs are not to cure dementia in an individual but to help create effective changes that aid the management of the syndrome progression by the following:^24,25

• Through improving the person’s cognition in areas such as memory, concentration, language skills, or reasoning that usually come along with an effect on the person’s performance in real-life situations or an associated improvement in the person’s well-being, self-esteem, mood, and behavior.
• Through improving the person’s ability to function in real-life, everyday situations, helping to maintain the person’s independence for as long as possible. These are seen in cases ranging from mild to severe forms of dementia.
• Through the reduction of distress and mood disturbances in the person with dementia, by reducing depression and anxiety or by increasing adjustment or coping in the early stages of dementia.
• Through enhancing the person’s quality of life with quality care and adequate psychosocial support.
• Through positive changes in the caregiver; these can include reduced depression, distress, or anxiety; reduced burden; increased coping skills; less distress regarding difficult behaviors; improved understanding and support from family and friends; and enhanced quality of life.
• Through changes in disturbing and distressing behaviors, such as aggression, inappropriate sexual behavior, or restlessness. Depending on the behavior and the factors contributing to it, the goal may be to reduce the frequency of the behavior, or its severity; where the behavior does not appear to be causing problems for the person with dementia, the goal may be to reduce the impact of the behavior on others, including family caregivers or care workers.

TYPES OF NONPHARMACOLOGICAL TREATMENTS

One way of categorizing the nonpharmacological methods of managing dementia can be categorizing them on the basis of nature of symptoms, which would appear like the following:²⁶

• Cognitive/emotion-oriented interventions
  • Reminiscence therapy
  • Simulated presence therapy (SPT)
  • Validation therapy
• Sensory stimulation interventions
  • Acupuncture
  • Aromatherapy
  • Light therapy
  • Massage/touch
  • Music therapy
  • Snoezelen multisensory stimulation
  • Transcutaneous electrical nerve stimulation (TENS)
• Behavior management techniques (BMT)
• Other psychosocial interventions
  • Animal-assisted therapy
  • Exercise

ROLE OF PSYCHOTHERAPIES IN DEMENTIA MANAGEMENT

ALTERNATIVE MEDICINE THERAPIES FOR DEMENTIA

SENSORY STIMULATION THERAPIES FOR DEMENTIA

PHYSIOTHERAPY AND EXERCISE FOR DEMENTIA

BRIEF PSYCHOTHERAPIES FOR DEMENTIA

YOGA AND MEDITATION

In a way, both yoga and meditation are “brain exercises” that engage different parts of the brain based on the components of practice (breathing, movement, postures, chanting, visualization, and concentration) and can help the brain form new connections and recover from injuries or to stimulate neuroplasticity. Yoga may play a role in prevention and improve symptoms and quality of life for patients and their caregivers alike. Studies have also found that yoga and meditation may aid socializing and feel better. Yoga and meditation may also help prevent dementia to an extent.^59,60

OCCUPATIONAL THERAPY

Tailored activities programs (TAP) are one of occupational therapies that research has found to be effective that focuses on reducing undesirable behaviors associated with dementia. The principle of TAP is the selection of activities that are specifically tailored to the patient according to his/her abilities, interests, and roles. The program also helps caregivers to develop an increased sense of self-efficacy by offering trainings to simplify activities and help them adapt for future functional declines of the patient as well as to generalize the strategies to other contexts.⁶¹

COGNITIVE REHABILITATION FOR DEMENTIA

The impact of cognitive interventions on the BPSD is still not well-known because most of studies have focused on improving global or specific cognitive functions. Considering the importance of the relationship between cognitive interventions and BPSD, research trials of cognitive programs have been evaluated to find a significant reduction of delusional symptoms with a large effect size; however, aberrant motor behavior increased significantly in the treatment condition when compared to the control group.⁶²

GROUP PSYCHOTHERAPY APPROACHES

The goals of group therapy include creation of an emotional climate of acceptance and warmth among the group members, which helps patients to learn to accept themselves and their feelings. There is frequent intervention by the therapist to help facilitate social interaction for patients whose communication ability is impaired. Group therapy allows an opportunity for patients to experience the feelings of being part of a group, to ventilate feelings, opportunity for them to reminisce about past accomplishments and give new meaning to their lives, and to create a platform for patients to achieve a sense of self by expressing personal opinions in an environment of respect and acceptance.^63,64

SUPPORT GROUPS FOR CAREGIVERS OF PATIENTS WITH DEMENTIA

The basis for using support groups as a psychosocial intervention is the assumption that when individuals who have experienced a similar traumatic event gather together to share their concerns, they can cope with the stress better than on their own. Limited data from two studies suggest that support groups may be of psychological benefit to people with dementia by reducing depression and improving quality of life and self-esteem.⁶⁴ The role of support groups with respect to dementia has chiefly revolved around support groups for caregivers to relatives with dementia. Recently, the notion has been expanded to include individuals with dementia themselves. Goals include grief work, achieving balance between maintaining independence and facing dependence, responding to altered interpersonal interactions, and provision of information about the disease and community resources.⁶⁵

FAMILY THERAPY AND COUPLES THERAPY FOR DEMENTIA

Techniques that may be utilized in relationship counseling include focusing on one issue at a time, seeing the patient and their family separately and together, utilizing relationship as a resource, role playing, balanced focus on strengths and deficits, and collaborative stance. Role playing is a very useful technique to help the person with dementia and his or her family reduce negative statements and replace it with supportive statements that indicate kindness and compassion.³ Systematic research regarding couples and family therapy for people with dementia that could guide clinical approach is lacking.^66,67

DEMENTIA REHABILITATION

Dementia can be conceptualized in terms of social disability as well as that highlights the way in which symptoms such as memory problems—and the secondary effects of these, such as loss of confidence or negative reactions from others—affect the possible way of engaging in activities and participating in society. Activity limitation and participation restriction can be tackled from two directions, community and personal perspective. From a community perspective, the focus is on reducing external barriers by expanding awareness, changing public attitudes, and creating accessible, dementia-friendly environments. From a personal perspective, the focus is on enabling people with dementia to participate in everyday life and in their families and communities, in a way that is meaningful to them. This entails rehabilitation.⁶⁸

HOLISTIC TEAM/LIAISON APPROACH TO DEMENTIA

A liaison approach is ideal for the treatment of any illness, and so for dementia. The liaison approach to manage dementia involves the following professionals in team work for an ideal outcome:⁶⁹

HOME-BASED CARE IN DEMENTIA—TIPS FOR CAREGIVERS

Home-based care is a cost-effective model that is comfortable to the patients as they are in familiar surroundings. It includes both pharmacotherapy and nonpharmacological management. The carers should be properly educated about the clinical features of disease as caring for a person with dementia has been identified as a chronic stressor that places caregivers at risk for physical and emotional problems.⁷¹

Care for patients with dementia involves management with the caregivers who are a part of the first line of care. Apart from the traditional nonpharmacological means of management and psychoeducation, there are several simple to-do practices that one can follow to make home living and diurnal routines easy for patients with dementia.⁷²

ANIMAL-ASSISTED THERAPY FOR DEMENTIA

Animal-assisted therapy is gaining popularity as part of therapy programs in residential-aged care facilities. Humans and pet dogs, birds, and cats respond to quiet interaction with a lowering of blood pressure and an increase in neurochemicals associated with relaxation and bonding. These effects may be of benefit in ameliorating BPSD. Several small studies suggest that the presence of a dog reduces aggression and agitation, as well as promoting social behavior in people with dementia. One study has shown that aquaria in dining rooms of dementia care units stimulate residents to eat more of their meals and to gain weight but is limited by the small number of facilities studied. There is preliminary evidence that robotic pets may provide pleasure and interest to people with dementia. It is important that the animal and the therapist are trained before using animal-assisted therapy for dementia.^78–80

LIMITATIONS OF NONPHARMACOLOGICAL APPROACHES

Each therapy has its advantages and disadvantages; however, the key lies in training the caregivers, professional, and family. In fact, it is a research-oriented suggestion that the most common interventions for BPSD are not necessarily specific therapies but working with carers or nursing home staff to change the attitudes and behavior of those in their care (at a home and fundamental care level). The field of dementia care is expanding. Training, management of behavioral and psychological symptoms, follow-up sessions, and implementation of treatment programs require further intensive work in order to intensify the efficacy of the nonpharmacological interventions for dementia care.⁸¹

BUILDING RESILIENCE FOR DEMENTIA—PREVENTION FOR ELDERS

A few suggestions for the cognitive exercises which may be woven into one’s daily routine to build resilience for dementia are the following:⁸²

• Brush your teeth with your right as well as your left hand.
• Change the day, date, month, and year in a manually operated calendar.
• Take whiff of a perfume and try to identify which perfume it is.
• Solve the newspaper crossword puzzle.
• Learn a new language by learning one word of that new language every week and using that word in a day-to-day communication.
• Play games which will enhance one’s cognition (cards, chess, and carrom).
• Innovate and play some new games.
• Learn singing or learn to play a musical instrument.
• Learn cooking, taste food items, and try to recognize the ingredients.
• Indulge in mental maths while doing any calculations; minimize the use of a calculator.
• Learn to do magic tricks.
• Learn to operate a new gadget like mobile phone, computer, microwave, and washing machine.
• Learn new applications or games.
• Learn beading, knitting, painting, craft, photography, or any new skill.
• View your photo album, and recall and share the events with family and friends.
• Travel and visit new places with the help of a map.
• Indulge in destressing exercises such as laughing, relaxing, yoga, meditation, reading, and listening to music, etc.
• Socialize.
• Sleep well at least for a period of 8–10 hours per day.
• Eat chocolates and pamper your taste buds along with eating a healthy diet.
• Allow sexual expression between couples in old age when possible.

CONCLUSION

The field of dementia care is ever expanding and new therapies get added to those available in the management of dementia regularly. It is prudent that NPTs become an integral part of dementia management and rehabilitation programs. While this is important, one must always combine multiple approaches together as no one method fits the bill in the long-term management of dementia. There is also a need for a team approach in the management of patients with dementia with sound communication and planning between team members. Medical management must be aimed at synergizing with nonpharmacological management to enhance the long-term management and quality of life of patients with dementia.

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