Abstract

Background: The progression of cognitive symptoms in dementia is typically accompanied by functional loss and marked by the emergence of neuropsychiatric symptoms and challenging behaviours. These complications occur throughout the course of the disease, and are associated with more time spent caregiving, greater risk for nursing home placement, staff caregivers’ burnout, and higher care costs. The widespread use of antipsychotic drugs to treat neuropsychiatric and behavioural symptoms is disputed by evidence suggesting these drugs have few benefits, and may pose significant risks, for patients with dementia. Policies are now in place to reduce the use of antipsychotic medication and clinical guidance recommends using non-pharmacological alternatives. However, while evidence of effectiveness of alternatives has been reviewed, it has not previously been pulled together in one place.

Methods: An overview was carried out of the findings from systematic reviews on the effectiveness of nonpharmacological alternatives to the use of antipsychotics in patients with dementia across care settings. Standardised assessment tools (AMSTAR) and a rigorous methodology were used to ensure transparency and quality. In all, 30 systematic reviews were included, covering 651 unique studies and identifying 19 types of non-pharmacological interventions. Seventeen reviews focused on interventions delivered in long-term care settings; six on interventions delivered in the community and the rest on interventions delivered across care settings.

Results: The most consistent evidence for effectively managing behavioural and psychological symptoms was found for behaviour management techniques delivered by professional staff, and for staff and caregiver training and support. There was promising evidence for four other alternative treatments: physical activity / exercise; massage / touch therapies; multi-sensory stimulation (e.g. snoezlen, aromatherapy) and music therapy – although the evidence for these was not as robust, either because the primary studies were not as rigorous, the results were mixed or the evidence available was limited. Only validation therapy was consistently ineffective. For the vast majority of treatments, however, the evidence was inconclusive, either because it was inconsistent across primary studies, or these studies were of poor quality, or the evidence was almost totally lacking.

Implications: The general lack of high quality evidence – in particular, on the direct impact of alternatives for reducing the use of antipsychotics – inhibits making recommendations, and suggests that further, high quality research is needed to inform future policy and practice. Such research would include robust designs, large enough samples to draw meaningful conclusions, greater consistency in measurement of patient outcomes and most importantly, clearer descriptions of the context in which interventions are delivered to enable a better understanding of issues to do with implementation, cost-effectiveness and transferability across care settings. This research could not only improve the quality of life of patients with dementia and their caregivers but also provide the necessary evidence to help mitigate the impact of psychiatric symptoms and challenging behaviours on long-term care.

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