About three-quarters of people with dementia are affected by neuropsychiatric symptoms (NPS). This is a broad group of symptoms including depression, sleep problems, apathy, psychosis and aggression.
Of course, many people with dementia still live at home and are cared for by their spouse or other primary carer. These neuropsychiatric symptoms can have a major impact on the quality of life of the patient and also their carer, and sometimes they can be the deciding factor in sending someone into a nursing home.
Evidence shows that drug treatments for NPS are not hugely effective and the drugs can sometimes produce serious side effects, so there’s understandable interest in non-pharmacological treatments for these symptoms.
A new systematic review in the American Journal of Psychiatry brings together the published randomised evidence in this field and concludes that non-drug treatments delivered by family caregivers can improve neuropsychiatric symptoms in people with dementia.
Methods
The reviewers searched a good range of databases and found 23 trials, including a total of 3,279 caregiver and patient pairs. Sixteen of the trials were well conducted and well reported RCTs that could be included in their random effects meta-analysis.
The reviewers excluded trials that dealt with comorbid severe mental illness, respite care or drug treatments.
The included trials covered lots of different treatments and so the researchers grouped them into categories. Some were directed at caregivers (skills training, education, enhanced support, self-care techniques) and others took a different tack (e.g. activity planning, environmental design, exercise for the care recipient or collaborative care with a health professional).
They used Cohen’s d to measure effect sizes and investigated publication bias and heterogeneity as you would hope in this kind of systematic review.
Results
Non-drug treatments delivered by family caregivers can improve neuropsychiatric symptoms in people with dementia
The reported results are quite modest, but the review did find enough of an effect for caregiver interventions to consider targeting these approaches at people with dementia and their carers living in the community.
- When compared with usual care:
- Caregiver interventions improved behavioural and psychological symptoms of dementia (0.34, 95% CI 0.20 to 0.48; p<0.01)
- Caregiver interventions also improved caregiver reactions to these symptoms (0.15, 95% CI 0.04 to 0.26; p=0.006)
The reviewers found no sign of publication bias from their funnel plot.
Conclusions
The authors concluded:
Non-pharmacological interventions delivered by family caregivers have the potential to reduce the frequency and severity of behavioral and psychological symptoms of dementia, with effect sizes at least equaling those of pharmacotherapy, as well as to reduce caregivers’ adverse reactions.
This review highlighted the heterogeneity of outcome measures used across the different included studies. It’s seems logical to suppose that some neuropsychiatric symptoms (e.g. apathy) may respond better to non-drug treatments than others (e.g. psychosis), but the analysis did not contain sufficient data to explore these differences.
The bottom line here is that there are lots of promising approaches that can be taught to caregivers in a relatively short time period (9-12 sessions) that can have a positive impact when delivered individually in the home setting. These interventions are free from adverse effects and whilst they may not help everyone, they are likely to improve symptoms for many.
Link
Brodaty H, Arasaratnam C. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012 Sep;169(9):946-53. doi: 10.1176/appi.ajp.2012.11101529. [PubMed abstract]
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[…] More important patient-relevant outcomes such as long-term side-effects, quality of life, are not routinely measured in trials on antipsychotics, let alone reported. Questions such as why they work for some people and not others, direct comparisons between antipsychotic treatment and alternative drug or non-drug treatments, what happens when you withdraw antipsychotics and so on are also much less well researched. Happily the situation is changing, albeit slowly. But at the moment there is simply less good-quality evidence available for non-drug treatments. What evidence there is, however, is positive, as covered in several Mental Elf blogs on the subject, most recently Non-drug treatments delivered by family carers can improve neuropsychiatric symptoms in people with …. […]