European Geriatric Medicine 6 (2015) 134–150
Available online at
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Research paper
Non-pharmacological interventions as a best practice strategy in
people with dementia living in nursing homes. A systematic review
E. Cabrera *, C. Sutcliffe, H. Verbeek, K. Saks, M. Soto-Martin, G. Meyer, H. Leino-Kilpi,
S. Karlsson, A. Zabalegui On behalf of the RightTimePlaceCare Consortium1
School of Health Sciences TecnoCampus, University Pompeu Fabra, Avda. Ernest Lluch 32, 08332 Mataró, Barcelona, Spain
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 3 April 2014
Accepted 2 June 2014
Available online 26 June 2014
Background: Two-thirds of nursing home residents suffer from dementia and there is a need for effective
and efficient interventions with meaningful outcomes for these individuals. This study aims to identify
current best practices in non-pharmacological interventions in nursing homes.
Methods: A systematic literature review was conducted, following the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) declaration guideline. Studies and Randomized
Controlled Trials (RCT) evaluating non-pharmacological interventions focused on improving the Quality
of Care (QoC) and/or Quality of Life (QoL) of people with dementia (PwD) living in nursing homes were
included. For individual study evaluation, the Cochrane Collaboration risk of bias assessment tool was used.
Results: A total of 31 articles were included and five main categories emerged: psychosocial and
educational, physical activity, sensorial therapies, staff-focused interventions and complex interventions. Psychosocial interventions were the most exhaustively studied and evaluated interventions. Few
studies related to physical therapy were identified and they did not provide enough evidence of their
effectiveness. Therapeutic touch was revealed to have positive effects on residents with dementia.
Conclusion: Psychosocial interventions have been shown to have the potential to improve the QoL and
QoC of people with dementia in nursing homes. Before implementation of the intervention, it is
recommended that activities are adjusted according to residents’ characteristics and external factors
controlled to achieve effectiveness and to structure a well-designed intervention. However, there is not
enough evidence to support the effectiveness of non-pharmacological interventions in general. Further
well-designed research is needed on non-pharmacological interventions in nursing facilities.
ß 2014 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords:
Non-pharmacological interventions
Best practice
Dementia
Nursing home
Systematic review
1. Background
Nursing homes (NH) provide medical attention to people who
do not require hospitalization but cannot live alone. The majority
of residents are elderly and evidence shows that two-thirds suffer
from some type of dementia [1]. Dealing with the consequences of
this disease: neuropsychiatric symptoms, functional difficulties,
cognitive problems, deterioration of daily living activity skills, etc.,
* Corresponding author.
E-mail addresses: [email protected] (E. Cabrera), [email protected] (C. Sutcliffe), [email protected] (H. Verbeek),
[email protected] (K. Saks), [email protected] (M. Soto-Martin), [email protected] (G. Meyer), Helena.leino-kilpi@utu.fi (H. Leino-Kilpi),
[email protected] (S. Karlsson), [email protected] (A. Zabalegui).
1
University of Witten/Herdecke (DE): Gabriele Meyer PhD, RN, professor (scientific coordinator, WP 1 leader), Astrid Stephan MScN, RN, Anna Renom Guiteras, geriatrician,
Dirk Sauerland Dr.rer.pol., professor (WP 4 and 6 leader), Dr Ansgar Wübker, Patrick Bremer dipl. oec. Lund University (SE): Ingalill Rahm Hallberg, professor (WP 2 leader);
Ulla Melin Emilsson, professor; Staffan Karlsson, PhD, Christina Bokberg, MSc, Connie Lethin, MSc. Maastricht University (NL): Jan P.H. Hamers, PhD, RN, professor (WP 3
leader); Basema Afram, MSc; Hanneke C. Beerens, MSc, RN; Michel H.C. Bleijlevens, PhD, PT; Hilde Verbeek, PhD; Sandra M.G. Zwakhalen, PhD, RN; Dirk Ruwaard, MD, PhD,
professor. University of Manchester (UK): David Challis, professor (WP5 leader); Caroline Sutcliffe MSc; Dr David Jolley; Sue Tucker, MSc, RN; Dr Ian Bowns; Brenda Roe,
professor; Alistair Burns, professor. University of Tartu (EE): Kai Saks, MD, PhD, professor (WP 5 leader); Ene-Margit Tiit, PhD, professor; Jelena Leibur, MD, MBA; Katrin
Raamat, MA; Angelika Armolik, MA; Teija Tuula Marjatta Toivari, MA, RN. Gerontôpole, University of Toulouse (FR): Dr Maria Soto; Agathe Milhet; Dr Sandrine Sourdet; Sophie
Gillette; Bruno Vellas, professor. University of Turku (FI): Helena Leino-Kilpi, PhD, RN, professor; Jaana Koskenniemi, MNSc, RN, researcher; Riitta Suhonen, PhD, RN, professor;
Matti Viitanen, MD, PhD, professor; Seija Arve, PhD, RN, docent; Minna Stolt, PhD, podiatrist; Maija Hupli, PhD, RN. – Fundació Privada Clinic per la Recerca Biomedica, Hospital
Clinic of Barcelona (ES): Adelaida Zabalegui PhD, RN (WP 5 leader); Esther Cabrera PhD, RN (Tecnocampus Mataró), Montserrat Navarro PhD, RN Ester Risco MNSc, RN; Carme
Alvira MScN, RN; Marta Farre MScN, RN; Susana Miguel MScN, RN.
http://dx.doi.org/10.1016/j.eurger.2014.06.003
1878-7649/ß 2014 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
is complicated [2,3]. It is necessary to define management
strategies and improve quality of care (QoC) and quality of life
(QoL) of dementia sufferers (PwD) [4]. Health professionals need to
be aware of what constitutes best practice in this population and
setting [5].
There is a need for effective and efficient interventions with
meaningful outcomes. The effectiveness of the pharmacological
intervention approach is moderate at best and the potential for
side effects is substantial. Studies indicate non-pharmacological
interventions use a wide range of approaches and have demonstrated effectiveness in treating behavioral and psychological
symptoms with no adverse effects [6]. A recent meta-analysis
showed how non-pharmacological interventions reduced the
frequency and severity of dementia symptoms [7]. However, there
is scarce evidence of positive results in residential settings [8].
This review is part of an extensive European research project
called ‘RightTimePlaceCare’ (RTPC) – (HEALTH-F3-2010-242153
supported by the European Commission in the 7th framework
program). The RTPC project includes eight European countries:
Germany (coordinator), England, Estonia, Finland, France, Spain,
Sweden and The Netherlands, and aims to develop best practices in
European dementia care [9].
To identify current best practices in non-pharmacological
interventions, a systematic literature review was conducted. The
concept of best practice (BP) is defined as ‘‘a program, activity or
strategy that has the highest degree of proven effectiveness
supported by objective, comprehensive research and evaluation’’
[10]. BP can improve QoC and QoL of PwD. We considered nonpharmacological interventions as treatment modalities to decrease
pain, improve mobility and QoL, enable the patient to lead a normal
social life and prevent health problems. The research question
underlying the study was: Which non-pharmacological interventions are considered best practice (improving QoC and/or QoL) for
people with dementia living in long-term care facilities?
2.2.2. Exclusion criteria
Systematic review and meta-analysis.
2.3. Data extraction strategy
Data extraction was independently carried out by the same two
authors (AZ, EC). Information was organized from each study and
included: study design (sample size, randomization, blinding, and
study follow-up), patients’ profiles, intervention characteristics,
variables, results and outcomes.
2.3.1. Critical analysis of study quality
For individual study evaluation the Cochrane Collaboration risk
of bias assessment tool was used [12], describing the potential risk
of study design bias. This provides a framework for assessing a trial
and helps researchers to judge effectiveness.
The following study design aspects were evaluated in every RCT
for potential bias risk:
method of sequence generation (randomization);
allocation concealment;
rationale for blinding of participants, personnel and outcomes;
incomplete outcome data;
selective outcome reporting;
other potential sources of bias such as conflict of interest.
Each item was rated as being potentially at low-risk (‘‘Yes’’),
high-risk (‘‘No’’) or (‘‘?’’) unclear. All items were rated in duplicate
by two members of the research team until agreement was
reached.
2. Methods
3. Results
This systematic review followed a pre-specified protocol
(available on request) developed using the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA)
declaration guideline [11].
3.1. Study selection
2.1. Search strategy
The search was performed in two phases. The first at the
beginning of 2012 and the second in 2013 in MEDLINE, (accessed
through PubMed), CINAHL and the Cochrane Methodology Register
(accessed through the Cochrane Library). One researcher performed the search under the supervision of an expert librarian. The
search strategy used the key terms: ‘‘Alzheimer disease’’ OR
‘‘dementia’’ AND ‘‘patient care’’ OR ‘‘nursing home’’ OR ‘‘long-term
care’’ AND ‘‘Non-pharmacological interventions’’.
2.2. Eligibility criteria
2.2.1. Inclusion criteria
Studies evaluating one or more non-pharmacological interventions focused on improving the QoC and/or QoL of PwD living in
nursing homes;
Randomized Controlled Trials (RCT);
studies in the English language published in peer review
journals;
articles published from 1990 to 2013.
135
The screening process is summarized in Fig. 1. The research
yielded 2911 articles. One thousand one hundred and twenty were
in the English language and published between 1990–2013.
Duplicated studies were excluded, leaving 830 articles. To ensure
search accuracy, two authors independently examined all titles
and abstracts, producing a sample of 193 studies. The same two
researchers independently reviewed the full text of the selected
articles and approved inclusion. Any lack of agreement was
resolved by consensus, leaving a final sample of 31 RCTs.
3.1.1. Study characteristics
Thirty-one RCTs met the inclusion criteria [13–38,40–44] and
five main intervention categories emerged (Table 1): psychoeducational [13–21], physical activity [22–25], sensorial [26–34],
staff-focused [35,36,37,38,40] and complex [41–44] (Table 2).
Nineteen studies were two-arm RCTs [14,15,17–19,21–23,25,26,
29–32,35,38,40,41,43] and 12 were three-arm or more [13,16,20,
24,27,28,33,34,36,37,42,44].
Six studies were double-blind. Not all RCTs conducted longterm follow-up. Follow-up of between 0–1 month post-intervention was done in 4 trials [16,31,32,34], 1–3 months in 3 trials
[14,19,38], 4 months in one trial [42] and six months in 3 studies
[23,25,36].
All studies focused on managing the consequences of dementia
in PwD care homes, 4 addressed to care home staff [35–38] and
3 studies for family members [17,19,40].
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
136
and reminiscence therapy. In this review, three distinct intervention types were identified: individual activities [13–17]; group
activities [18,19]; and reminiscence therapy [20,21].
Records identified through
database searching
(n=2911)
Records after applied
inclusion criteria
(n=1120)
Duplicates (n=290)
Results after duplication
extraction
(n=830)
Articles screened on the
basis of the title and abstract
Final sample
(n=193)
Full-text articles assessed for
eligibility
Articles included in the
review
(n=31)
Fig. 1. Flow diagram of search strategy process.
3.2. Intervention effect
The review was done by categories.
3.2.1. Psychosocial and educational interventions
Psychosocial interventions most frequently mentioned in the
literature were caregiver interventions, multi-sensory stimulation
3.2.1.1. Individual psychosocial and educational activities. Of the 5
RCTs evaluating individualized psychosocial and educational
activities, one carried out in 2000 consisted of a walking-talking
program developed in pairs but assessed individually, to improve
communication, ambulation and functioning [13]. This was
compared to a conversation-activity group and a no-treatment
group. Non-significant differences between groups were obtained.
Authors observed that participants with moderate cognitive
impairment had higher outcome scores than those with more
severe dementia. Two behavioral interventions to reduce disruptive behaviors and improve affect were tested by Beck et al.
(2002) [14]. The first included activities of daily living (ADL) for
45–60 minutes. The second assessed self-esteem, safety and
security, and personal identity and cognitive understanding. A
third group had a combination of both. The three treatment groups
showed positive effects but disruptive behavior was not reduced
with respect to controls.
An intervention to decrease agitation in residents with
moderate dementia, the Balancing Arousal Controls Excesses
(BACE) intervention, was tested on 36 participants and compared
with a no-treatment group [15]. This intervention controlled daily
activity schedules to obtain a balance between residents’ high- or
low-arousal states. The effect size was moderate and suggested the
BACE intervention was effective (average change 8.43 points pre to
post-test, effect size of 0.7).
A 4-arm RCT evaluated the effects of activities in the ‘‘needdriven dementia-compromised behavior model’’ on behavioral
symptoms [16]. There were four groups: functional level activity
(FL), personality style of interest activity (PSI), functional level/
personality style mixed (FL + PSI), and a control group. Participants
in the FL group became less engaged compared with the other 2
groups, PSI group participants suffered less agitation and FL + PSI
subjects demonstrated less positivity.
Table 1
Non-pharmacological interventions for people with dementia living in nursing homes.
A. Psychosocial and educational interventions [16–24]
A.1. Individualized activities
A.2. Group activities
A.3. Reminiscence therapy
B. Physical activity interventions [25–28]
B.1. Individual and group exercise
C. Sensorial interventions [29–37]
C.1. Light therapy
C.2. Music therapy
C.3. Sensory stimulation
C.4. Therapeutic touch
D. Staff-focused interventions [38–41,43]
D.1. Training sessions, care management
D.2. Emotion-oriented care
E. Complex interventions [44–47]
Multidisciplinary interventions
Addresses the individual, social and environmental aspects of a person’s life. Can prevent or minimize the
disability associated with neurological impairment
Provides stimulation and socialization that help to slow physical and cognitive deterioration
Aims to increase levels of well-being and provides pleasure and cognitive stimulation. RT involves helping a
person with dementia to relive past experiences, especially those that might be positive and personally
significant
Therapeutic exercise developed in groups and physical activity program focused on the individual
Aims to improve fluctuations in diurnal rhythms that may account for night-time disturbances and ‘sundown
syndrome’ (recurring confusion or agitation in the late afternoon or early evening) in people with dementia
Aims to involve engagement in a musical activity (e.g., singing or playing an instrument), or merely listening to
songs or music
Multi-sensory approaches usually involve using a room designed to provide several types of sensory
stimulation such as light (often in the form of fibre optics which can move and be flexible), texture (cushions
and vibrating pads), smell and sound. The use of these resources is tailored to the individual and therefore not all
of the available forms of stimulation may be used in one session
It is a technique in which the hands are used to direct human energy for healing purposes. There is usually no
actual physical contact
Provides training for staff in nursing homes and consists of programs on how best to manage residents with
dementia. The training imparts knowledge about dementia care components
Aims to improve emotional and social functioning, and ultimately the quality of life, of persons suffering from
dementia by supporting them in the process of coping with the cognitive, emotional and social consequences of
the disease and by linking up with individual functional possibilities
Interventions where different health and social professionals are involved
Table 2
Characteristics of included studies.
Interventions
Author
and year
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
3-arm RCT
n = 74
EG1 = 25
EG2 = 30
CG = 19
Yes
No
No
Alzheimer diseases; living in
NH, MMSE
<20; ability to
walk 5 meters
with or without
assistance
To investigate the
effects of a walking/
talking program on
residents’ communication, ambulation, and level of
function when
there were two
residents to one
care provide (2:1)
The walk and talk intervention (EG1)
consisted of 30 minutes of walk and talk
session 5 times a week for 16 weeks
Participants in the talk intervention
(EG2) received a session of 30 minutes
of conversation sitting with the therapist 5 times a week for 16 weeks
Participants in the control (CG) group
did not receive any treatment
Beck et al.,
2002 [14]
2-arm RCT
n = 127
EG1 = 28
EG2 = 29
EG3 = 22
CG1 = 29
CG2 = 19
Yes
No
Yes
1m
2m
Patients with
dementia; >65
years old; living in NH
To test the effect of
two interventions:
(1) an activities of
daily living and
(2) a psychosocial
activity intervention and (3) a
combination of the
two, in reducing
disruptive behaviors and improving affect in nursing
home residents
with dementia
Kovach et al.,
2004 [15]
2-arm RTC
n = 78
EG = 36
CG = 42
Yes
Yes
No
Residents in
NH; MMSE
<15; with agitation by
nurses report
To test the effectiveness of the
theoretically driven
BACE (i.e. Balancing
Arousal Controls
Excesses) intervention in decreasing
agitation in residents of long-term
care with moderate
or severe dementia
Three intervention groups: (1) an educational intervention implemented
during bathing, grooming, dressing and
noon meal and tried to promoted
cognitive and physical abilities (45–
60 min/day); (2) the PSA intervention
contained 25 standardized modules
with five psychosocial areas to meet
psychosocial needs for communication,
self-esteem, safety and security, personal identity and cognitive understanding of participants respecting
their cognitive and physical abilities
(15–30 min/day); (3) combination of
ADL + PSA (90 min/day)
Control groups consisted on: (1) placebo and (2) no intervention
The BACE intervention consists of three
phases: (1) patient assessment;
(2) diagnose and plan a correction of
the arousal imbalance; (3) implement a
new activity schedule
There were non-statistical differences between groups.
Residents with moderate cognitive impairment had higher
scores on social communication (P = 0.000), communication
of basic needs (P = 0.000) and
overall communication
(P = 0.000)
The subgroups did not differ
significantly on ambulation;
however there was a tendency
for residents with moderate
cognitive impairment to walk
longer distance
Results from the analysis of
affect reported an increase on
positive affect but not
decreased negative affect.
There were no significant
results on reducing disruptive
behaviors
A. Psychosocial and educational
A.1. Individual
Cott et al.,
2002 [13]
Balancing time spent in higher
and lower arousal states
through manipulation of activity schedules is effective in
decreasing agitation levels of
people with dementia (P = 0.04)
Results not generalizable
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Study
137
138
Table 2 (Continued )
Interventions
Study
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
Kolanowski
et al., 2011
[16]
3-arm RCT
n = 128
EG1 = 32
EG2 = 33
EG3 = 31
EG4
(AC) = 32
Yes
Yes
1 w after
Residents in
NH;
MMSE < 24
>65 years old
To test the main
and interactive
effects of activities
derived from needdriven dementiacompromised
behavior model for
responding to
behavioral symptoms in nursing
home resident
Participants were assigned one of four
groups: (1) functional level (FL: activities tailored to their skill level but
opposite their personality style of
interest); (2) personality stile of interest (PSI); (3) FL + PSI: activities tailored
to their functional skill level and
personality style of interest and (4)
active control (AC: activities functionally challenging and opposite their
personality style of interest). All groups
received 20 minutes twice per day five
days each week for three consecutive
weeks of activity
Hanson et al.,
2011 [17]
2-arm RCT
n = 256
EG = 127
CG = 129
Yes
Yes (NH)
No
Informal caregivers of people
with dementia
living in NH
To test whether a
decision-aid
improves quality of
decision-making
about feeding
options in
advanced dementia
Participants in EG received a structured
decision-aid providing information
about dementia, feeding options and
the outcomes, advantages, and disadvantages of feeding tubes and assisted
oral feeding, to take home and research
assistants prompted them to discuss it
with healthcare provide
During the intervention participants in FL group became less
engaged (P = 0.009), participants in PSI less agitation
(P = 0.007), participants in
FL + PSI demonstrated less passivity (P = 0.025). Agitation
increased in AC (P = 0.046) and
in FL + PSI (P = 0.003). Results
compared with baseline scores
to one week post-intervention,
mood improved in the FL + PSI
(P = 0.017), anxiety in FL group
(P < 0.0001) but decreased in
pleasure FL (P < 0.0001) and PSI
(P < 0.001)
Participants in EG group had
significantly lower score on the
Decision Conflict Scale than CG
whom had usual care
(P < 0.001). EG had higher mean
knowledge scores than control
(P < 0.001)
Residents in EG were more
likely to receive a dysphasia
diet (P = 0.04)
Fritsch et al.,
2009 [18]
2-arm RCT
n = 20 NH
EG = 10 NH
CG = 10 NH
Yes
No
No
Residents from
a freestanding
NHs with
dementia special care units
(SCUs)
To assess the
impact of a TimeSlips (TS) intervention, a group story
telling program
that encourages CE
among PWDs and
those who care for
them
The TS program (EG) involved groups of
10–12 residents once a week for 1 hour
for 10 weeks
The facilitators asked open-ended
questions about a picture and recorded
residents’ responses on pads of paper,
making it clear that there were no
incorrect answers. Facilitators then
wove the response into a story, periodically reading it back to the participants as it progressed, to maintain the
groups’ focus and enthusiasm. Participants were encouraged to participate in
storytelling. The story was later transcribed and displayed to the residents
A.2. Group
Staff in the EG had greater
social eye contact (P < 0.001),
touch (P < 0.001) and verbal
communication (P < 0.001).
They also had less devalue
attitudes to the residents
(P = 0.013) and more positive
views of these persons
(P < 0.001) compared with the
CG
Residents in the EG reported
challenging behaviors
(P < 0.05), more general alertness (P < 0.05), fear or anxiety
(P < 0.01) and sadness
(P < 0.05) than the CG that
reported a more neutral affect
(P < 0.01)
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Author
and year
Table 2 (Continued )
Interventions
Study
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
Ducharme
et al., 2005
[19]
2-arm RCT
n = 178
EG1 = 45
CG1 = 41
EG2 = 51
CG2 = 41
Yes
No (CG)
No
Adult daughter
primary caregivers of people
with dementia
living in a NH
To test the persistent and delayed
effects of an intervention program
entitled ‘‘Taking
care of myself’’ on
selected mental
health outcomes of
daughter caregivers of a relative
with dementia living in a long-term
care setting
Ten 90-minute weekly sessions for
groups of six to eight caregivers. Discussion: (a) the empowerment of
caregivers; (b) reframing, a coping
strategy
The program covers 6 themes: (1) feeling at ease when visiting my relative;
(2) expressing my point of view to
healthcare staff; (3) avoiding emotional
torment; (4) dealing with small daily
losses and being prepared for the
ultimate loss of my relative; (5) identifying and calling upon my support
network and community services; and
(6) reorganizing my life after my
relatives’ institutionalization and taking care of myself
Successful effects in the EG
were maintained at T3 in perceived availability of informal/
formal support, competence
dealing with healthcare staff
and reframing
Control by self, perceived
threat, role overload and perceived challenge was maintained in T2 but not in T3
More caregivers in both EG
obtained successful outcomes
for competence dealing with
healthcare staff (P < 0.05),
reframing (P < 0.05), and perceived availability of informal/
formal social support
(P < 0.001)
3-arm RCT
n = 60
EG1 = 20
EG2 = 20
CG = 20
Yes
Yes
No
Patients with
vascular
dementia living
in nursing
homes facilities
To evaluate the
beneficial effect of
the group reminiscence approach
(GRA) in patients
with vascular
dementia on the
aspect of cognitive
and observed
behavioral parameters
Results did not demonstrate an
improvement on cognitions
and behaviors
The authors concluded that
non-pharmacological interventions including psychosocial
ones can be tested in an
objective and reproducible
manner
2-arm RCT
n = 102
EG = 51
CG = 51
Yes
Yes
No
Residents from
five facilities
with dementia
To test the hypothesis that structured
group reminiscence
therapy could prevent the progression of cognitive
impairment
Participants in the experimental group
received 1 hour groupal reminiscence
approach (GRA) once a week for 3
months and 1 hour session of reality
orientation (RO)
A second group of participants received
a conversation sessions (SC) received
1 hour session of RO and conversation
The third group was the control group
(CG). Participants in the CG received
support care
Sessions were carried out among psychologist, speech therapist, occupational therapist, medical social worker,
and nurse
EG received eight group sessions of
60 min (one per week and 8-week
period). Themes: first meeting, childhood experiences, older flavor of food,
old style music, festivals, my family,
younger age, my achievements
A.3. Reminiscence therapy
Ito et al., 2007
[20]
Wang, 2007
[21]
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Author
and year
No significant difference was
found at the baseline in any
demographic variables besides
the length of the hospitalization (P < 0.01). 92 subjects
completed the study. No statistically significant differences
between the pre-test scores of
the two groups relative of three
variables (MGDS-SF, CSDD).
Results demonstrated that the
intervention affected cognitive
and affective function as measured by MMSE and CSDD
(P = 0.0015 and 0.026)
139
140
Table 2 (Continued )
Interventions
Author
and year
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
2-arm RCT
n = 37
EG1 = 36
EG2 = 36
Yes
No
No
Patients with
dementia living
in long-term
care facility
To evaluate the
efficacy of a kitbased activity
intervention compared to a time and
attention control in
reducing apathy
and improving
quality of life in 37
patients with
dementia
Results indicated an improvement on apathy in both groups
‘‘kit’’ (P = 0.055) and ‘‘one on
one’’ (P = 0.007). Participants in
control intervention ‘‘one on
one’’ also improved on quality
of life (P = 0.030). Analysis
between groups reported no
significant differences on
apathy and quality of life
Eggermont
et al., 2009
[23]
2-arm RCT
n = 66
EG = 34
CG = 32
Yes
No
Yes (6
weeks)
Persons with
dementia living
in nursing
homes. Mean
age of participants was
84.59 years
To examinate the
effects of hand
motor activity on
cognition, mood
and the rest-activity rhythm in older
people with
dementia
Tappen et al.,
2000 [24]
3-arm RCT
n = 65
EG1 = 23
EG2 = 22
EG3 = 20
Yes
Yes
No
Patients with
Alzheimer living in longterm care facilities. Participants mean age
86.7 years
To compare a combined walking and
conversation intervention on functional mobility in
nursing home residents with AD
Two interventions were used: G1 ‘‘the
Geriatrics Network Kit’’ (experimental
intervention) that is a structured
activity helpful to apathetic patients. It
is an individualized intervention.
Patients’ choice an activity of their
preference (five types: geography, fun
foods, farm animals, vegetables and
musical instruments). Activities are
classified in two degrees of difficulty
(30 min). EG2 – ‘‘one on one’’ (time and
attention control). The therapist introduces a question or talk about some of
participant interests. The intervention
is individualized and unstructured and
last for a half of an hour
Hand motor activity (6 weeks) by
recreational therapists or psychology
master students. Participants in the
experimental condition (EG) received a
program based on fingers movements:
pinching a soft ball, handling a rubber
ring, among others. Instructions were
reinforced by an instructional video.
Participants in the control condition
(CG) received conversation on selfinterest without memory or verbal
objective
Three conditions were compared provided three times a week for 16 weeks:
(1) walking; (2) conversation; and
(3) walking + conversation (GE). Walking condition (W). Participants received
30 minutes assessment to delay fatigue
three times a week for 16 weeks.
Participants were encouraged to
ambulate as far as possible. During the
sessions, there were no conversation,
researchers only answer questions.
Conversation participants received
30 minutes of conversation treatment
about topics of personal interest.
Walking + conversation (WC); participants received walking and conversation simultaneously within the
30 minutes session
B. Physical activity
Politis et al.,
2004 [22]
Results revealed an improvement on mood domain postintervention (P < 0.01) but this
effect was not found at followup. No significant differences
were founded on memory
domain, cognition or activity
Results indicated a percentage
decrease in distance walked in
W (20.9%) and C (18.8%) groups.
Participants in the WC group
maintained their level of functional mobility (2.5%)
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Study
Table 2 (Continued )
Interventions
Study
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
Conradsson
et al., 2000
[25]
2-arm RCT
n = 191
EG = 89
CG = 99
Yes
Yes
Yes (6 m)
>65 years,
dependent on
assistance with
a MMSE score
10 or more living in residential care
facilities
To evaluate the
effects of a highintensity functional
exercise programme on
depressive symptoms and psychological well-being
among older people
dependent in
activities of daily
living (ADL) and
living in residential
care facilities
A high-intensity functional weight
bearing exercise program developed by
physiotherapists (PT)
Exercises were based on functional
tasks common in everyday life. Participants developed the exercise at a
highest intensity
Control group received a sitting activity
developed by an occupational therapist
(singing, watching films. . .)
Sessions (29) in both groups were
performed in groups (3 to 9 participants) and lasted 45 minutes over 13
weeks
No statistically significant
results were found on depression and well-being scores.
However, participants with
dementia in the exercise group
had an improvement on wellbeing scores post-intervention
(P = 0.03)
An individualized and multifactorial intervention may be
needed to influence depressive
symptoms or well-being in this
group of older people
2-arm RCT
n = 15
EG = 8
CG = 7
Yes
No
No
Residents with
dementia
To test the efficacy
of a bright light
therapy for agitated
behaviors in
dementia patients
residing in longterm care
BLT consisted of 1 hour per day of light
exposure for 4 weeks. During the
process, the patients kept their eyes
open and were allowed to make other
activities such listening to music,
watching TV, eating. . . Control condition received a lower light dose
Ancoli-Israel
et al., 2003
[27]
3-arm RCT
n = 92
EG1 = 30
EG2 = 31
EG3 = 31
Yes
No
No
Patients with
Alzheimer living in an institution
To evaluate the
effect of bright light
therapy (BLT) on
agitated behavior
in patients with
dementia living in a
nursing home
Dowling
et al., 2013
[28]
3-arm RCT
n = 70
EG1 = 29
EG2 = 24
CG = 17
Yes
No
No
Persons with
Alzheimer living in nursing
homes. Average
age 84 years
To test the effects of
morning or afternoon bright light
exposure compared
with usual indoor
light on the presence, frequency,
severity, and occupational disruptiveness of
neuropsychiatric
behaviors in NH
Professionals that carried out the
intervention were nurses
There were three intervention conditions: EG1 – morning bright light; EG2
– evening bright light; EG3 – morning
dim red light (control, placebo intervention)
Treatment were applied
Three experimental conditions were
tested during 11 weeks: (1) morning
bright light; (2) afternoon bright light
Control group
Participants in group 1 and 2 received
the same dose of bright light
All participants showed slight
improvement in nocturnal
sleep as well as in mean scores
on the Behave-AD, but this
were not statiscally significant
Participants in the EG improved
in nocturnal sleep from a mean
of 6.4 to 8.1 hours/night. Differences with the CG were
statistically significant
(P < 0.05)
Agitation and behaviors
There were no differences
among groups on agitation
levels
Participants in the morning
bright light reported a delay in
the acrophase of physical agitation (P = 0.028)
Statistical analysis showed
significant differences between
groups for agitation/aggression
when compared to control
group (P = 0.032), depression/
dysphoria (P = 0.042), aberrant
motor behavior (P = 0.021), and
appetite/eating disorders
(P = 0.011)
There were significant differences between morning and
afternoon light on agitation/
aggression scores at the end of
the intervention. In both
increased being greater in
morning light group (P = 0.009)
C. Sensorial
C.1. Light therapy
Lyketsos
et al., 1999
[26]
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Author
and year
141
142
Table 2 (Continued )
Interventions
Study
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
Burns et al.,
2009 [29]
2-arm RCT
n = 48
EG = 22
CG = 26
Yes
No
No
Persons with
dementia living
in nursing
homes
To assess the benefit of bright light
therapy (BLT) on
sleep disturbance
on people with
dementia living in a
nursing home
Professionals that developed the
intervention are not described
Two interventions were compared:
(1) experimental (GE): bright light
therapy; (2) control (GC): normal light
Results indicated an improvement for participants in the EG
in agitation post-intervention,
but data were not statistically
significant compared with the
CG (P = 0.51). Behaviors
increased in the CG but there
were no differences between
groups. In sleep duration, there
were no differences between
groups post-intervention
2-arm RCT
n = 47
EG = 23
CG = 21
Yes
No
No
People with
dementia
Documented
history of agitation/aggression
Residing in a
NH
To investigate the
effect of music on
agitated behaviors
and anxiety in older
people with
dementia living in
NH
The intervention was a live group music
programme delivered by two musicians. Each music session ran for
40 minutes, three mornings a week
Involved 30 min of musician-led
familiar song singing and 10-minutes of
pre-recorded instrumental music for
active listening
2-arm RCT
n = 100
EG = 49
CG = 51
Yes
No
Yes (1
month)
Persons with
dementia <65
years living in
nursing homes
facilities
To explore the
effectiveness of
group music intervention on agitated
behavior in elderly
with dementia and
living in NH
Participants in the experimental group
(EG) received 12 sessions of group
music intervention 30 minutes’ sessions a week for 6 weeks. The intervention was a modified version of Clair
and Bernstein protocol (1990) carried
out by therapists
Participants in the control group (CG)
performed usual daily activities
The outcomes were measured
by CMAI-SF (behavior disturbance instrument) and RAID
(anxiety symptoms instruments)
Scores for the music intervention group were lower than
those reported by the reading
group
Analyses showed that there
was a significant increase in the
frequency of verbal aggression
over time (P < 0.005)
There was no evidence to
indicate that the music programme was more effective to
indicate that the reading group
activities
Agitated behaviors scores
decreased in the EG compared
with CG, differences were statistically significant (P < 0.001).
At 1-month post-intervention,
the positive effect was also
statistically significant
(P < 0.001). Results in physical
non-aggressive behaviors
revealed a statistically significant difference in the EG postintervention (P = 0.004) and at
one month follow-up
(P = 0.015). Results in verbal
non-aggressive behaviors
revealed a statistically significant difference in the EG postintervention (P = 0.010) and at
one-month follow-up
(P = 0.037). Results in verbal
aggressive behaviors revealed a
statistically significant difference in the EG post-intervention (P = 0.021) but not at
follow-up
C.2. Music intervention
Cooke et al.,
2011 [30]
Lin et al.,
2010 [31]
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Author
and year
Table 2 (Continued )
Interventions
Author
and year
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
C.3. Multi-sensor stimuli
Baker et al.,
2003 [32]
2-arm RCT
n = 136
EG = 61
CG = 65
In three
different
countries
(UK, Netherlands,
Sweden)
Yes
No
Yes
Persons with
dementia.
Average age of
participants
was 81–83
years
To assess whether
multi-sensor stimuli (MSS) is more
effective in changing the behavior,
mood and cognition of older adults
with dementia living in a NH
Intervention was developed by nursing
staff, occupational therapists or psychologist assistants
Participants in the experimental group
(EG) received multi-sensory stimulation (MSS) intervention
Participants in the control group (CG)
received eight activity sessions
There were no differences
between groups on behaviors,
mood or cognition
However, participants were
less bored/inactive
(P < 0.0001), enjoying (P < 0.01)
and happy/content (P < 0.0001)
after sessions
C.4. Therapeutic touch
Woods et al.,
2005 [33]
3-arm RCT
n = 57
EG1 = 19
CG1 = 19
CG2 = 19
Yes
Yes
No
People with
dementia living
in special care
units and in
long-term care
units. Participants were
aged 67–93
years
To examine the
effect of therapeutic touch on the
frequency and
intensity of behavioral symptoms of
dementia of people
living in NH
Three intervention conditions:
(1) therapeutic touch (TT), experimental group (EG). Participants received TT
on neck and shoulders. The intervention was conducted in the patient room
and lasted 5–7 minutes for three days;
(2) placebo therapeutic touch (PTT).
Participants received a mimic treatment resembled TT; (3) control group
(CG). Participants received routine care.
3-arm RCT
n = 60
EG1
(TT) = 17
EG2
(ST) = 16
CG = 18
Yes
Yes
Yes (1 and 2
weeks)
Persons with
dementia, 65
years or older,
living in longterm care facility
To compare the
effectiveness of
therapeutic touch
(TT), simulated
therapeutic touch
and usual care on
disruptive behavior
in people with
dementia living in
NH
Participants received therapeutic touch
once a day (5 days). The practitioners
and volunteers spent approximately
30–40 min implementing their treatment. The five phases of non-touch. TT
were administered by practitioners
who had completed the advanced level
of TT training: (a) TT per day/5 days;
(b) ST treatment per day/5 days; and
(c) usual care for 5 days
Measurement of the resident’s agitation was taken: (a) 2 hours after each
treatment; (b) 24 hours after the final
treatment; (c) 1 week after the final
treatment; and (d) 2 weeks after the
final treatment
Results indicated an improvement of behaviors statistically
significant in the EG (P = 033)
compared with the PTT and CG
The experimental group was
more effective in decreasing
behavioral symptoms of
dementia than usual care, while
the placebo group indicated a
decreasing trend in behavioral
symptoms of dementia compared to usual care.
There was no significant difference across the three groups
in the incidence of physically
aggressive (x2 = 2.28, P = 0.32)
and verbally agitated behaviors
(x2 = 1.99, P = 0.37). The intervention of TT did not have a
greater influence on these
behaviors than did the simulated TT intervention or the
usual care group approach
There were significant differences across the three intervention groups in the number
of physically non-aggressive
behaviors displayed during the
5 days (x2 = 5.98, P < 0.05).
Post-intervention—Time 6
(24 hours after final intervention) to time 8 (2 weeks after
final intervention). For all three
behavior categories, there was
no significant difference across
intervention groups in the frequency of the behaviors (physically aggressive behaviors,
x2 = 1.35, P = 0.51; physically
non-aggressive behaviors,
x2 = 1.37, P = 0.51; verbally agitated behaviors, x2 = 3.14,
P = 0.21)
Hawranik
et al., 2008
[34]
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Study
143
144
Table 2 (Continued )
Interventions
Author
and year
Study
Sample
D. Staff-focused interventions
D.1. Training sessions, psychosocial management
Testad et al.,
2-arm RCT
n = 142
2005 [35]
(PwD)
EG = 55
CG = 87
(staff)
EG = 14
CG = 22
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
Yes
Yes
No
Persons with
dementia
(PwD) living in
nursing homes.
Average 84
years
To assess a stafftraining program
intervention to
reduce problem
behaviors and the
use of restraints in
residents with
dementia living in
NH
Participants in the experimental group
(EG) participated in a six hours seminar
focused on dementia, aggressions,
problem behaviors, decision-making
process and alternatives to restraints. A
manual was developed to guide the
seminar. Staff received 1 hour monthly
guidance session for six months
Participants in the control group (CG)
received usual treatment
There were three conditions:
(1) dementia training program; (2) peer
support program; and (3) control condition. EG1. Dementia training program
plus peer support program, participants
in E2. Dementia training program. GC
were in a wait list control. Dementia
training program consisted of eight 60–
90 minutes sessions of a combination of
didactic and experiential learning.
Program focused on skills to use in
caring for residents with dementia
especially on behaviors. Peer support
program aimed to facilitate informal
support on five peer sessions of 30–
60 minutes. Topics of the sessions were
identified for the staff
At the end of the intervention
process, there was a significant
decrease of the use of restraints
in the EG compared with the CG
(P = 0.017). However, agitation
scores increased in the EG at six
months (P = 0.017) and these
scores were also higher than in
the CG (P = 0.052)
Davison et al.,
2007 [36]
3-arm RCT
G1: staff
(90)
EG1 = 29
EG2 = 35
CG = 26
G2: residents (113)
EG1 = 35
EG2 = 46
CG = 32
Yes
No
Yes (6 m)
90 staff (nurses
and unlicensed
nursing assistants)
113 persons
with dementia,
mean age 85
living in nursing homes
To evaluate the
impact of an eightsession training
program for aged
care staff in managing dementiarelated challenging
behaviors
Kuske et al.,
2009 [37]
3-arm RCT
n = 321
EG1 = 107
EG2 = 104
CG = 110
Yes
?
No
Staff of residents with
dementia
To study the effectiveness of a nursing home stafftraining program
designed to
improve the interaction between
residents with
dementia and their
caregivers
The training program (EG1) was
developed to increase the caregivers’
motivation and facilitate the transfer of
their knowledge into practice. Participants in this group received 13 one
hour sessions twice a week over 13
weeks
Participants’ in the EG2 received 13 one
hour sessions of relaxation training. The
objective was to give caregivers the
opportunity of relaxing for one hour
while at work
The CG did not receive any intervention
Results showed no effects of
training program and peer
support on staff burnout at T2
and T3. Results on self-efficacy
of dementia care showed a
significant effect of training
from T1 to T2 (P < 0.001) and at
T1 to T3 (P < 0.05) compared
with CG. A positive effect of
peer support were found at T2
to T3 (P < 0.05). On nursing
performance in GE1 increase by
32.2% at T2 and 32.6% at T3.
Participants in GE2 increased
11.5% at T2 and 18.9% at T3.
Participants in CG decreased
3.7% at T2 and increased 4.9% at
T3 compared with T1 scores
The impact on residents (frequency of behaviors) did not
reach significance
Participants in the EG1
increased their competence
(P = 0.056) compared with the
CG. In addition, the use of
physical restraints in the EG1
decreased compared with EG2
and CG
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Randomized
Table 2 (Continued )
Interventions
Study
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
Deudon et al.,
2009 [38]
2-arm RCT
n = 306
EG = 174
CG = 132
Yes
Yes
Yes (12
weeks)
Persons with
dementia, older
than 65 years
living in nursing homes
To evaluate the
effectiveness of a
staff education
intervention to
manage behavioral
and psychological
symptoms of
dementia (BPSD) in
older people with a
diagnosis of
dementia
Professionals that conducted the
intervention were ‘‘independent professionals’’
A staff education intervention and
training program to manage behavioral
and psychological symptoms of
dementia (BPSD). Participants in the
program received 90-minutes teaching
session on BPSD and the use of four
instruction cards that summarized
practical advice. The first card contained a general guideline for the
management of opposition, denial of
care, aberrant motor activity, agitation,
aggression, delusions, hallucinations
and screaming. The second card
explained how to decreased BPSD on
daily care. The other two cards contained recommendations on nonpharmaceutical interventions as for
example eating or bathing
Participants in the experimental group reported less behaviors (P < 0.001) and agitation
(P < 0.001) between baseline to
week 8
Positive effect on agitation
were maintaining at week 20
(P < 0.001)
Participants in the control
group did not have a significant
evolution/outcome? On behaviors, but reported an increase
on agitation (P < 0.05) at week
20 compared with the experimental group
2-arm RCT
8 NH EG
8 NH CG
Participants:
EG = 100
CG = 94
Yes
No
No
Persons with
dementia
(PwD), age 65
or older living
in nursing
homes
Nursing assistants (NA)
To examine the
effect of integrate
emotion-oriented
care on nursing
home residents
with dementia and
nursing assistants
Two nursing interventions were
developed for this study: (1) usual care
as control group (CG): working in
accordance with the guidelines of the
Model-Care plan of the Dutch association of Nursing Home Care; (2) offering
integrated emotion-oriented care in
combination with usual care. Wards
included in the EG received training and
supervision in the application of integrated emotion-oriented care for 9
months. The content of the training
course was: basic training emotionoriented care for all staff members
involved on the care, advanced course
‘‘emotion-oriented care worker’’ for five
staff members on each ward, a training
course ‘‘adviser emotion-oriented care’’
for one staff member per ward
Central issues of the course were: the
experiences of the residents, making a
life story, being alert to how the past
may affect the present and acknowledgement of the residents’ experiences.
The course lasted 10 days during nine
months
Results for PWD: participants
in the EG improved on maintaining an emotional balance
(P = 0.04) and on maintaining a
positive self-image (P = 0.04)
Results for NA: participants in
the EG reported less stress
(P = 0.003) reactions than participants in the CG
D.2. Emotion-oriented care
Finnema
et al., 2005
[39]
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Author
and year
145
146
Table 2 (Continued )
Interventions
Author
and year
Sample
Randomized
Blind
F-Up
Participants
characteristics
Objective
Intervention
Results
2-arm RCT
n = 44
EG = 33
CG = 22
Yes
Yes
No
Geriatric
patients with a
mean age 83.4
years (65 to 95)
and slight to
moderate
dementia living
in long-term
care geriatrics
To compare the
effect of a two different occupational
therapy strategies
in people with
dementia living in
NH
Participants in the experimental group
(EG) received functional rehabilitation
(T1) and a reactivating occupational
therapy program (T2) for 24 weeks. T2
was carried out twice a week during
1 hour in groups of 5–6 participants.
Participants in T2 were stimulated by
memory training, sensorimotor functions, and self-management
Participants in the control group (CG)
received a functional rehabilitation
programme for 24 weeks, comprising
functional occupational therapy, physiotherapy and speech therapy
Christofoletti
et al., 2008
[42]
3-arm RCT
n = 54
EG1 = 11
EG2 = 12
CG = 14
SI
SI (1)
NO
>65 years old
Nursing home
residents
Dementia diagnoses
To analyse the
effects of two
interventions on
the cognition and
balance of institutionalized elderly
people with
dementia
Bellantonio
et al., 2008
[43]
2-arm RCT
n = 100
EG = 48
CG = 52
Yes
No
No
Persons with
dementia living
in dementia
assisted facilities. Mean age
of participants
was 81.1 to
83.4
To determine
whether a multidisciplinary team
intervention minimizes unanticipated transitions
from assisted living
for people with
dementia
To analyse the effects of two interventions on the cognition and balance of
NH residents with dementia
EG1. Interdisciplinary program with
physiotherapy (on specific kinesiotherapeutic exercises that stimulated strength, balance and cognition
such as concentrated attention, recognition, immediate memory, working
memory and praxis), occupational
therapy (group activities, by means of
arts and craft activities) and physical
education (walking sessions and exercises to stimulate strength, balance,
motor coordination, agility and flexibility) 2 h sessions/5 times a week
EG2: Physiotherapy (on specific kinesiotherapeutic exercises that stimulated strength, balance and cognition
such as concentrated attention, recognition, immediate memory, working
memory and praxis), 3 times a week
CG: No motor intervention
Experimental group (EG): intervention
was developed by a multidisciplinary
team: geriatrician and geriatric
advanced practice nurse made recommendations on behaviors; physical
therapist, evaluated physical function,
gait and balance; dietician, evaluated
nutritional status and diet recommendations; and a medical social worker,
assessed guardianship issues, longterm planning and psychosocial
adjustment of residents and family. The
team met bimonthly and was available
for consultation during the
study period
Control group (CG): consisted on usual
clinical care. A team approach was not
employed
There was a significant effect on
cognitive performance, psychological functioning, wellbeing and depression in both
groups post-intervention
Comparing two groups EG
improved on cognitive performance at 12 weeks. At 24
weeks the EG improved in
cognitive performance
(P < 0.001), psychological
functioning (P < 0.001), wellbeing (P < 0.001) and depression (P < 0.001) compared with
the CG
In EG1, there was a improvement in functional capacity
(balance) when comparing
with control group (P < 0.05)
In EG2, there was an improvement, too when comparing
with CG (P < 0.05)
No changes were observed on
the participant’s cognition
E. Complex interventions
Bach et al.,
1995 [41]
Results indicated that 55 residents experienced an unanticipated transition; differences
between groups were no statistically significant. The intervention reduced the risk of
transition, but results were not
statistically significant
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
Study
Results showed that agitation
increases in UC and results
persisted at follow-up
(P = 0.03). On PCC agitation
decreases post-intervention
and at follow-up (P = 0.01).
Participants in DCM had no
statistical significant results
(P = 0.77), but compared with
UC participants in the DCM
group reduced agitation at follow-up (P = 0.04)
Participants in the DCM
reduced antipsychotic drug
doses compared with PCC postintervention and at follow-up.
The DCM intervention was
effective in reducing falls
compared with UC (P = 0.02)
and PCC (P = 0.03)
Three conditions: (1) dementia care
mapping (DCM). Two care staff were
trained on DCM observation for 6 h per
day for two days. Observation included
positive aspects of well-being residents; (2) person-centred care (PCC)
plans were implemented for 4 months
3. usual care (UC)
To investigate the
effectiveness of
person-centered
care and dementia
care mapping compared with each
other and with
conventional
dementia care and
to examine
whether either
intervention can
decrease need-driven dementiacompromised
behaviors
Persons with
dementia living
in nursing
homes. Mean
age of participants was 83–
85 years
No
n = 289
EG1 = 109
EG2 = 98
CG = 82
Chenoweth
et al., 2009
[44]
3-arm RCT
Yes
Yes (4
months)
Results
Intervention
Objective
Participants
characteristics
F-Up
Blind
Randomized
Sample
Study
Author
and year
Interventions
Table 2 (Continued )
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
147
One trial was identified as aiming to improve decision-making in
256 residents. This consisted of an audio or print decision-aid on
feeding options in advanced dementia [17]. The intervention was
compared with usual care. Experimental group participants (EG)
had a significantly lower score on the decision conflict scale than
controls (CG). Knowledge scores also increased and residents were
more likely to receive a dysphagia diet.
3.2.1.2. Group psychosocial and educational activities or interventions. Two RCTs evaluated a psychosocial and educational group
activity [18,19]. One study was addressed to informal caregivers [19],
specifically adult daughters, and the other to the residents themselves
[18]. The first study evaluated a program entitled ‘‘Taking care of
myself’’ and consisted of 90-minute, weekly session group discussions about emotional issues. Experimental group participants
achieved benefits in perceived availability of informal/formal
support, and competence when dealing with healthcare staff and
reframing. The second, a storytelling intervention entitled ‘‘TimeSlips’’ consisted of opened-ended questions administered to elicit
responses used to generate new stories. Generally, the EG showed a
positive response, social communication was enhanced and fewer
negative attitudes were observed compared with controls [19].
3.2.1.3. Reminiscence therapy. Reminiscence therapy is a common
intervention in dementia care although too few high-quality or
sufficiently robust studies were found. In our review, two RCTs
explored group reminiscence [20,21]. It involves discussion of past
activities, events and experiences with another person or group. A
3-arm RCT evaluated effects on behavior and cognitive symptoms
[20]. The technique was compared with a conversation group and a
support group. After authors identified some study design
limitations, no improvements were obtained in any EG. However,
another reminiscence group intervention [21] evaluated effectiveness in preventing cognitive impairment progression and enhancing affective function. The results showed improvement,
compared with controls, in most variables including cognition
and depression.
3.2.2. Physical activity
No evidence for the effectiveness of physical interventions in
improving QoC or QoL was found in our search. Five studies
showed positive effects but did not reach statistical significance.
One RCT tested a ‘‘geriatric network kit’’ intervention to reduce
resident apathy as an individual, standardized structured one-toone individual, unstructured activity [22]. Apathy reduction and
QoL improvement was observed in both groups but between
group analysis revealed no significant differences. Results of hand
motor activity revealed an improvement in the mood domain in
the EG although the effect was not found at follow-up [23].
Evidence shows that combined programs [24] could significantly
improve functional mobility when compared with single-activity
only. Similar results were reported by Conradsson et al. (2000)
[25] in a high-intensity functional exercise program seemed to
have no influence on depressive symptoms and psychological
well-being.
3.2.3. Sensorial interventions
Several studies examined sensorial interventions. We identified
four therapy types: light [26–29], music [30,31], multi-sensory
stimuli [32], and therapeutic touch [33,34]. Nine trials met the
inclusion criteria. This review revealed that therapeutic touch
interventions seem to show the most positive effects.
3.2.3.1. Light therapy. Four RCTs tested the effect of Bright Light
Therapy (BLT) on behavioral symptoms [26–29]. Two 3-arm
RCTs compared the effect of morning BLT and afternoon/evening
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E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
BLT with normal light [27,28]. The other two compared one
single type of BLT with usual light [26,29]. When comparing the
effect on dementia symptoms between morning and evening, no
differences were found. Limited evidence was found of reduction in agitation and aggression among those receiving BLT
[28,29].
3.2.3.2. Music intervention. Two RCTs observed the effect of music
on behavioral symptoms [30,31]. The first tested a live-music
intervention on decreasing agitation and anxiety [30]. This was
compared to a reading intervention. Results showed no significant
differences in agitation and anxiety. Nonetheless, an experimental
study [31] consisting of a group music-listening intervention
showed a statistically significant decrease in agitated behavior
scores in the EG at three time-points.
3.2.3.3. Multi-sensory stimuli interventions. One RCT identified a
multi-sensory stimuli (MSS) intervention consisting of 8 standardized sessions. Effect was assessed through changing behavior,
mood and cognition. Controls followed an exercise program [32].
No differences were found between groups in behaviors, mood or
cognition.
3.2.3.4. Therapeutic touch. Therapeutic touch interventions were
effective in decreasing behavioral symptoms. Two RCTs compared
therapeutic touch (TT), with simulated therapeutic touch (STT) and
usual care [33,34] on agitation and aggressive behavior in older
PwD. Physical, aggressive behavior decreased significantly in those
who received therapeutic touch.
3.2.4. Staff-focused interventions
Two subcategories were identified in this group: training
sessions [35–38] and an emotion-oriented care approach [40].
Reviewed trials revealed positive effects of these interventions
in residents and health professionals in terms of knowledge,
satisfaction, stress, restraint use and general organizational
structure.
3.2.4.1. Training sessions, psychosocial management. Four RCTs
evaluated separate staff-training programs [35–38]. Differences
were found between studies. A training program aimed to increase
caregiver motivation and transfer of knowledge into practice [37].
Compared with usual care only, caregivers showed greater caring
competencies. Restraint use was also assessed in a 2-arm RCT [35].
There was a significant decrease in the use of restraints postintervention compared to the CG, but this was not maintained over
time (6 months).
Another staff-training intervention [36] consisting of eight
sessions of a combination of didactic and experiential learning was
evaluated in comparison with a peer support program facilitating
informal support through five peer support sessions and a notreatment group. This study evaluated effects over time. Good selfefficacy results were found on intervention groups although no
beneficial effects on staff burnout were observed.
3.2.4.2. Emotion-oriented care interventions. The emotion-oriented
care approach seeks to improve emotional and social functioning
by supporting PwD when coping with the cognitive, emotional and
social consequences of the illness [39]. One RCT assessed emotionoriented care through an intervention intended to improve or
maintain emotional balance and positive self-image [40]. Less
stress reaction in the EG was reported when compared with the notreatment group. The other RCT was evaluated by family members
of PwD. EG participants had a positive opinion of the way nursing
staff treated the residents. Emotion-oriented care was more
effective in emotional adaptation to nursing homes among people
with mild to moderate dementia. There was no added value for
those with severe dementia.
3.2.5. Complex interventions
These types of interventions consist of many components that
act alone and in conjunction. Most are multidisciplinary interventions.
Bach et al. (1995) [41] compared the effect of two physical
occupational therapy activities. The experimental group received
occupational therapy (OT) and functional rehabilitation (FR) while
controls received functional rehabilitation alone. Both groups
demonstrated positive effects on cognitive performance, psychological functioning and well-being but a comparatively greater
improvement was found in the EG.
Another study compared an interdisciplinary program with
physiotherapy only and a no-treatment group [42]. Both experimental groups showed improvement in functional capacity but no
changes were observed in cognition.
Bellantonio et al. (2008) [43] conducted a multidisciplinary
team intervention in two dementia-specific assisted facilities.
Intervention group subjects had lower rates of permanent nursing
facility admission, emergency department visits, hospitalization
and death than controls.
A cluster RCT [44] assessed the effect of person-centered care
and dementia-care mapping on reducing agitation. Results showed
lower levels of agitation However, while fewer falls were recorded
in sites using mapping, more falls were found among those
receiving person-centered care.
4. Discussion
Non-pharmacological interventions evaluated here focused on
improving the QoL of PwD.
The most frequent interventions evaluated through RCTs were
psychosocial and educational, sensorial and staff-focused interventions.
Previous systematic reviews show that psychosocial interventions offer the best available evidence for effectiveness in dementia
treatment [45] but our review found little consistent evidence. It
appears that although positive outcomes can be identified when
managing behavioral disturbances, it is unclear what causes
results to be maintained over time. Recent research has identified
the need for strong evidence of their effectiveness [46]. Lawrence
et al. (2012) showed the benefits of these interventions on QoL and
recommend individual psychosocial interventions with a specialist
[47].
Behavioral disturbances or neuropsychiatric symptoms (NPS)
in residents are a main focus for interventions. Results indicate that
these programs can improve QoL and QoC. Negative effects have
not been observed but only one structured intervention comparing
agitation was found to be statistically significant [15]. Even in
reminiscence therapy, a well-established approach [48], we found
that there is a need to use a well-designed, structured intervention.
The second most frequent interventions were sensorial. Outcomes examine improvements in behavioral disorders. BLT had the
best results in agitation management [16–19]. Residents with
severe dementia showed the greatest improvement with BLT
[28,29]. A systematic review conducted by Ayalon et al. [51]
presented similar results. There was a significant reduction in NPS
after sensorial therapy although the authors concluded that many
of the interventions did not have a solid evidence-base.
Mobility can have a positive effect through specific physical
activity interventions but this is not due to exercise alone, rather it
is the social interaction during the walking activity which is
essential to improve compliance enough to produce mobility
E. Cabrera et al. / European Geriatric Medicine 6 (2015) 134–150
improvements [24]. This finding is similar to that by Cooper et al.
(2012) [49] that no significant QoL differences exist between EG
and CG in a kit-based activity.
Our findings are subject to several limitations. The PRISMA
research terms included ‘‘dementia’’, ‘‘Alzheimer’s disease’’ possibly
omitting studies related to non-pharmacological interventions not
identified in the study keywords. Our research method did not
include trials related to cognitive stimulation programs [50].
It is also questionable whether RCTs are the best evaluation
method. There are several difficulties associated with applying
blind study design in PwD [20].
All interventions studied called for evaluation of these
strategies within further trials to test reproducibility and generalizability. Although most trials support the hypothesis that the
intervention would benefit residents, this is concluded discretely.
Another relevant factor is the use of robust experimental designs.
Most authors reach their conclusions on the basis of very small
samples. Studies were also limited by sample heterogeneity, short
follow-up periods or insufficiently detailed description of instruments. We found very few reports attempted to blind the
assessment of outcomes. Moreover, most interventions had short
application periods or follow-up (weeks or a few months).
5. Conclusion
We conclude that there is insufficient evidence to determine
which non-pharmacological interventions should be included
among best practice recommendations.
Recommendation based on evidence and consensus is crucial
when identifying best practice for PwD. Based on our review, there
are non-pharmacological interventions which are effective with
respect to managing dementia symptoms and improving QoL and
QoC. Nonetheless, we would stress that it should be borne in mind
that lack of evidence of efficacy is not evidence of lack of efficacy.
Psychoeducational interventions should tailor activities to PwD
needs. There is still not enough evidence to support implementation of psychosocial, non-pharmacological interventions in PwD.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
Acknowledgments
We would like to express our gratitude to Montse Navarro, PhD,
Carme Alvira, MSc, Marta Farre, MSc, Susana Miguel, MSc, and Ester
Risco, MSc, for their participation during the search and data
extraction.
The RightTimePlaceCare study is supported by a grant from the
European Commission within the 7th framework program (project
242153). The authors acknowledge the support and management
provided by Gabriele Meyer, RN, PhD, Professor at Witten/
Herdecke University (scientific coordinator, WP 1 leader).
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