Pharmacological and Non-Pharmacological Interventions
Interventions used in the care treatment and support of people with dementia can be both pharmacological (drugs) and non-pharmacological. The latter include both environmental and behavioural modification. The section to follow will describe in broad terms these two types of interventions.
There is no cure for dementia nor are there any disease-modifying drugs available to combat Alzheimer’s disease and the related dementias. Rather certain drugs and only in some cases, address the symptoms of dementia by slowing down, in the short term, the progression of cognitive loss. These drugs commonly referred to as anti-dementia drugs, can only ever be prescribed by a medical doctor and the choice of drug will largely depend on the dementia sub-type.
How these drugs operate relate to the presence of Acetylcholine in the brain. The latter is a neurotransmitter or brain chemical required to facilitate communication between nerve cells in the brain. It becomes depleted with Alzheimer’s disease. For this reason, Alzheimer’s disease is often treated with a brand of drugs called Acetylcholine Inhibitors, developed to boost levels of Acetylcholine in the brain. There are three main Acetylcholine Inhibitors on the market. Their generic (non capitalized) and brand names (capitalized) are as follows- (i) donepezil (Aricept) (ii) rivastigmine (Exelon) and galantamine (Rimynl). Evidence from clinical trials demonstrate that the three drugs when prescribed at the recommended dose, offer statistically significant although clinically modest, benefits for functional (activities of daily living) and for cognitive and global outcomes. However to date there is no consistent evidence from clinical trials and system reviews that anti dementia drugs can improve quality of life.
A fourth and different type of drug, Memantine used for treating Alzheimer’s disease, works by blocking a chemical (glutamate) produced excessively in brain cells damaged by Alzheimer’s disease. Memantine tends to be prescribed to people with more severe dementia and may be used in combination with the Acetylcholinesterase inhibitors. Overall Memantine is associated with statistically significant global improvement as well as improvement in cognitive, functional and behavioural symptoms in individual with moderate to severe Alzheimer’s disease. Memantine also appears to have an effect on agitation, aggression and psychotic symptoms and may have the potential to reduce the need for antipsychotic medication.
As with all medications side effects can occur when taking any of these drugs. Acetycholinesterase Inhibitors can in a minority of cases cause nausea and other side effects including diarrhoea. Fewer side effects are associated with Memantine. All medications come in tablet form and rivastigmine also comes in a slow release patch that can be placed on the skin. All of these medications are expensive. Accordingly, if prescribed by your GP or specialist, it is advisable to apply for a medical card to offset their cost. In some instances, if refused a medical carc, it might be possible to apply to have your circumstances considered for the long term illness scheme card. Applications for the long term illness scheme are available from GPs and from local health centres.
Cognitive Stimulation Therapy (CST)
Cognitive Stimulation Therapy (CST) is one form of non-pharmacological intervention used to support people with mild to moderate dementia. During CST, The person with dementia is invited to participate in therapeutic sessions with a trained practitioner, skilled in interpersonal communication and dementia care. Each session consists of themed activities designed to engage and stimulate. These themes can include topics such as food, the use of money and/or discussions about current affairs. The initial sessions are generally held twice weekly, beginning with 14 sessions and followed by 24 maintenance sessions. CST is underpinned by key principles of person centeredness, respect, involvement, inclusion, choice, fun, the use of reminiscence, and of maximising potential and strengthening relationships. (Spector et al, 2006).
A common symptom of dementia is impaired short-term memory, however, often the person’s long-term memory remains intact for some time. Reminiscence therapy is an intervention enabling a person with dementia tap into his/her long-term memory and re-live past usually pleasurable experiences. It is considered amongst the most popular of all non-pharmacological interventions and can be enjoyed by both people with dementia, their relatives and health service professionals. It can take many formats, including life story work, simple or general reminiscence, and specific or special reminiscence.
Life story reminiscence work enables people to reflect back over their lives, either individually or in a group, and subsequently a book or similar record of the individuals’ life is, with his or her permission developed. Simple or general reminiscence is usually aimed at sharing common memories, encouraging sociability, educational or recreational objectives. It usually uses open‐ended prompts or multi‐sensory triggers to stimulate reminiscence on topics likely to be of interest to participants and unlikely to trigger painful memories. Specific or special reminiscence is usually undertaken with individuals or small, closed membership groups. As the name suggests it is more specialized, more individualized and may have an element of life review or self-evaluation Involved. The setting in which Reminiscence is delivered should be safe, noise free and devoid of any other major interruptions. For some people, Reminiscence may improve quality of life, promote confidence, and boost self-esteem. Different cues are used in Reminiscence such as rummage boxes, the internet, SONAS, music, or photograph albums. Reminiscence can also take place simply through conversation, which serves to trigger former memories and emotions.
In validation therapy, the practitioner attempts to communicate with the person with dementia by empathising with his or her feelings and with the meanings behind that person’s speech and behaviour. (Douglas et al, 2004). Stated simply, validation therapy aims to legitimate the person’s emotions, by acknowledging feelings, even though the latter because of the dementia may be based on misinterpretations or misperceptions. The aim is to make the person with dementia as happy as possible. (Jones, 1997). Obviously when a person with dementia is having delusions (false beliefs), which cause distress, validation therapy would not be recommended.
Reality Orientation helps the individual with dementia by reminding him/her about the present, by reinforcing self-identity, and by reminding that person of the surrounding environment. It can take many different forms including, cueing, signposts, calendars, notice boards, and often take place in groups or individually. In using Reality orientation, one must remain sensitive to the needs of the person with dementia, and keep in mind the fact that the person has a cognitive impairment and because of this may have difficulties remembering current events.
Physical exercise has been shown to benefit people who do not have a cognitive impairment, but exercise is also beneficial for people with dementia, particularly those who once led a very active life. People with dementia should always be encouraged to participate in some form of physical activity, although obviously this will need to be adapted as the dementia progresses. In adapting exercise programmes attention should be given to the person’s abilities, interests, preferences and to safety needs. There is also evidence demonstrating how physical activity can reduce depressive symptoms and behavioural disturbances such as agitation, noisiness and aggression (O’ Connor et al, 2009)
Multisensory Stimulation: Snoezelen Rooms
Multisensory stimulation in particular Snoezelen rooms are increasingly being used in long stay residential care settings to help people with dementia who may be restless or agitated. A Snoezelen room incorporates various aspects of multi sensory stimulation including fibre optics, light, water, colour, contrasting textures, soft furnishings, and quiet music. These features help to relax the person with dementia and can enhance communication between the person and his/her caregiver. Like many of the interventions discussed here, Snoezelen rooms are not appropriate for all people with dementia and research into the effectiveness of this intervention is limited.
Aromatherapy is a complimentary therapy often used in dementia care. Through smells, massage and bathing, aromatherapy can evokes pleasurable emotions for the person with dementia. Two of the essential oils used in aromatherapy for people with dementia are extracted from lavender and melissa balm. (Douglas et al, 2004). Significant reductions in agitation have been demonstrated in recent control trials. (Ballard et al, 2002)