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Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials

Published online by Cambridge University Press:  02 January 2018

Gill Livingston
Affiliation:
Unit of Mental Health Sciences
Lynsey Kelly
Affiliation:
Unit of Mental Health Sciences
Elanor Lewis-Holmes
Affiliation:
Unit of Mental Health Sciences
Gianluca Baio
Affiliation:
Departments of Statistical Science and PRIMENT Clinical Trials Unit
Stephen Morris
Affiliation:
Department of Applied Health Research
Nishma Patel
Affiliation:
Department of Applied Health Research
Rumana Z. Omar
Affiliation:
Departments of Statistical Science and PRIMENT Clinical Trials Unit
Cornelius Katona
Affiliation:
Unit of Mental Health Sciences, University College London, UK
Claudia Cooper
Affiliation:
Unit of Mental Health Sciences, University College London, UK
Corresponding
E-mail address:
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Abstract

Background

Agitation in dementia is common, persistent and distressing and can lead to care breakdown. Medication is often ineffective and harmful.

Aims

To systematically review randomised controlled trial evidence regarding non-pharmacological interventions.

Method

We reviewed 33 studies fitting predetermined criteria, assessed their validity and calculated standardised effect sizes (SES).

Results

Person-centred care, communication skills training and adapted dementia care mapping decreased symptomatic and severe agitation in care homes immediately (SES range 0.3–1.8) and for up to 6 months afterwards (SES range 0.2–2.2). Activities and music therapy by protocol (SES range 0.5–0.6) decreased overall agitation and sensory intervention decreased clinically significant agitation immediately. Aromatherapy and light therapy did not demonstrate efficacy.

Conclusions

There are evidence-based strategies for care homes. Future interventions should focus on consistent and long-term implementation through staff training. Further research is needed for people living in their own homes.

Type
Review articles
Copyright
Copyright © Royal College of Psychiatrists, 2014 

The number of people with dementia is rising rapidly with increased longevity. Although dementia’s core symptom is cognitive deterioration, agitation is common, persistent and distressing. Nearly half of all people with dementia have agitation symptoms every month, including 30% of those living at home. Reference Ryu, Katona, Rive and Livingston1 Four-fifths of those with clinically significant symptoms remain agitated over 6 months, Reference Savva, Zaccai, Matthews, Davidson, McKeith and Brayne2 and 20% of those initially symptom-free develop symptoms over 2 years. Reference Savva, Zaccai, Matthews, Davidson, McKeith and Brayne2 Agitation in dementia is associated with poor quality of life, Reference Wetzels, Zuidema, de Jonghe, Verhey and Koopmans3 because it is unpleasant, impedes activities and relationships, causes helplessness and anger in family and paid caregivers, Reference Draper, Snowdon, Meares, Turner, Gonski and McMinn4 and predicts nursing home admission, Reference Morris, Morris and Britton5 where the agitated behaviour adversely influences the environment. Reference Draper, Snowdon, Meares, Turner, Gonski and McMinn4 Several reviews, including our previous systematic review, Reference Livingston, Johnston, Katona, Paton and Lyketsos6 considered all neuropsychiatric symptoms’ management together. We found direct behavioural management therapies (BMT) with the person with dementia and specific staff education had lasting effectiveness, but this may be limited to affective symptoms. 7 A recent meta-analysis of family caregiver interventions for overall neuropsychiatric symptoms in dementia found an effect size of 0.23, but did not consider which symptoms improved. Reference Brodaty and Arasaratnam8

Neuropsychiatric symptoms in dementia are heterogeneous, therefore symptoms should be considered individually as successful strategies may differ. The one published, well-conducted systematic review of non-pharmacological management of agitation in dementia included only randomised controlled trials (RCTs) published before 2004 in English or Korean; it found just 14 papers and evidence of effectiveness only for sensory interventions. Reference Kong, Evans and Guevara9 The review did not consider whether interventions were effective only during the intervention or whether the effect lasted longer; the settings in which the intervention had been shown to be effective (e.g. in the community or in care homes); or whether the intervention reduced levels of agitation symptoms and was preventive or treated clinically significant agitation.

Psychotropic medication was routinely used to treat agitation but is now discouraged since benzodiazepines and antipsychotics increase cognitive decline, Reference Bierman, Comijs, Gundy, Sonnenberg, Jonker and Beekman10 and antipsychotics cause excess mortality and are of limited efficacy. Reference Maher, Maglione, Bagley, Suttorp, Hu and Ewing11 Similarly, citalopram has some efficacy but has cardiac side-effects and reduces cognition. Reference Porsteinsson, Drye, Pollock, Devanand, Frangakis and Ismail12 Cholinesterase inhibitors and memantine appear ineffective. Reference Howard, Juszczak, Ballard, Bentham, Brown and Bullock13,Reference Fox, Crugel, Maidment, Auestad, Coulton and Treloar14 Preliminary evidence suggests mirtazapine may reduce agitation. Reference Banerjee, Hellier, Dewey, Romeo, Ballard and Baldwin15 One RCT (not placebo-controlled) found analgesics improved agitation in people with dementia, with an effect size comparable to antipsychotics. Reference Husebo, Ballard, Sandvik, Nilsen and Aarsland16

Effective agitation management could in theory improve the quality of life of people with dementia and their caregivers, reduce distress, decrease inappropriate medication, enable positive relationships and activities, delay institutionalisation and be cost-effective. We aimed therefore to review systematically the evidence for non-pharmacological interventions for agitation in people with dementia, both immediately and longer-term; the costs of the successful interventions are reported in a separate paper. Reference Livingston, Kelly, Lewis-Holmes, Baio, Morris and Patel17

Method

We registered our protocol with the Prospero International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42011001370). We began electronic searches on 9 August 2011, repeating them on 12 June 2012. We searched PubMed, Web of Knowledge, British Nursing Index, the Health Technology Assessment (HTA) Programme Database, PsycINFO, NHS Evidence, System for Information on Grey Literature, The Stationery Office Official Publications website, the National Technical Information Service, INAHL and the Cochrane Library. Search terms were agreed in consultation with caregiver representatives, older adults and professionals. We hand-searched included papers’ reference lists and contacted all authors about other relevant studies. We translated eight non-English papers.

Inclusion and exclusion criteria

We included studies in any language that met the following criteria:

  1. (a) the participants all had dementia, or those with dementia were analysed separately;

  2. (b) the study evaluated non-pharmacological interventions for agitation, defined as inappropriate verbal, vocal or motor activity not judged by an outside observer to be an outcome of need, Reference Cohen-Mansfield and Billig18 encompassing physical and verbal aggression and wandering;

  3. (c) agitation was measured quantitatively;

  4. (d) a comparator group was reported or agitation was compared before and after the intervention.

We excluded studies if every individual was given psychotropic drugs or some participants received medication as the sole intervention. In this paper we report the highest-quality studies - randomised controlled trials (RCTs) with more than 45 participants - since none of the trials with a smaller sample size provided a full and appropriate sample size calculation.

Data extraction

The first 20 search results were independently screened by G.L. and L.K. to assess exclusion procedure reliability. No paper was excluded incorrectly. All other papers were screened by L.K. and E.L.H. If exclusion was unclear, L.K., E.L.H. and G.L. discussed and reached consensus. Data extracted from the papers (by L.K. and E.L.H.) included methodological characteristics; description of the intervention; whether the intervention was applied to the person with dementia, family caregivers or staff; statistical methods; length of follow-up; diagnostic methods; and summary outcome data (immediate and longer-term). Paper quality, including bias, was scored independently by L.K. and E.L.H., discussing discrepancies with G.L. and/or G.B. They used Centre for Evidence-Based Medicine (CEBM) RCT evaluation criteria (http://www.cebm.net/index.aspx?o=1025); this approach gives points for randomisation and its adequacy, participant and rater masking, outcome measures validity and reliability, power calculations and achievement, follow-up adequacy, accounting for participants, and whether analyses were intention to treat and appropriate. Possible scores range from 0 to 14 (highest quality). Where a randomised design was used but the intervention was not compared with the control group, we considered this a within-subject design, for example the study by Raglio et al. Reference Raglio, Bellelli, Traficante, Gianotti, Ubezio and Villani19 We assigned CEBM evidence levels as follows:

  1. (a) level 1b: high-quality RCTs (these were at least single-blind, had follow-up rates of at least 80%, were sufficiently powered, used intention-to-treat analysis, had valid outcome measures and findings reported with relatively narrow confidence intervals);

  2. (b) level 2b: lower-quality RCTs.

Intervention categories

The authors L.K., E.L.H. and G.L. categorised the interventions independently and then by consensus. The interventions were activities; music therapy (protocol-driven); sensory interventions (all involved touch, and some included additional sensory stimulation such as light); light therapy; training paid caregivers in person-centred care or communication skills (interventions focused on improving communication with the person with dementia and finding out what they wanted), with and without supervision; dementia care mapping; aromatherapy; training family caregivers in behavioural management therapies or cognitive-behavioural therapy (CBT); exercise; cognitive stimulation therapy; and simulated presence therapy.

Agitation level

We separated studies according to the inclusion criteria of participants in terms of level of symptoms of agitation: 1, no agitation symptom necessary for inclusion; 2, some agitation symptoms necessary for inclusion; 3, clinically significant agitation level; 4, level unspecified. We used the usual thresholds: a score above 39 on the Cohen-Mansfield Agitation Inventory (CMAI), Reference Cohen-Mansfield, Marx, Dakheel-Ali, Regier, Thein and Freedman20 and a score above 4 on the Neuropsychiatric Inventory (NPI) agitation scale, Reference Ryu, Katona, Rive and Livingston1 to denote significant agitation.

Statistical analysis

We decided a priori to meta-analyse when there were three or more RCTs investigating sufficiently homogeneous interventions using the same outcome measure, but no intervention met these criteria. To facilitate comparison across interventions and outcomes, where possible, we estimated interventions’ standardised effect sizes (SES) with 95% confidence intervals. Reference Hedges21 In some studies the outcome was measured and reported at several time-points during the intervention. We used data from the last time-point to estimate the SES, since individual patient data were not available to incorporate repeated measures in the calculation. We also recalculated results for studies not directly comparing intervention and control groups but reporting only within-group comparisons and with one-tailed significance tests, so some of our results differ from the original analysis.

Results

We found 1916 records, including 33 relevant RCTs with at least 45 participants (Fig. 1). Online Tables DS1 and DS2 list methodological characteristics, SES and quality ratings; Table DS1 contains the findings from interventions for which there appeared to be adequate evidence, and Table DS2 contains those for which there was not adequate evidence (either evidence that they were not effective or where there was simply insufficient evidence).

Efficacious interventions

Working with the person with dementia

Activities. Five of the included RCTs implemented group activities; those with standard activities reduced mean agitation levels, and decreased symptoms in care homes while they were in place. Reference Lin, Yang, Kao, Wu, Tang and Lin22,Reference Buettner and Ferrario23 One high-quality RCT found no additional effect on agitation of individualising activities according to functional level and interest, Reference Kolanowski, Litaker, Buettner, Moeller and Costa24 although two lower-quality RCTs did. Reference Kovach, Cashin, Taneli, Dohearty, Schlidt and Silva-Smith25,Reference Cohen-Mansfield and Jensen26 All studies were in care homes except one, in which some participants attended a day centre and others lived in a care home. Reference Cohen-Mansfield, Parpura-Gill and Golander27 None specified a significant degree of agitation for inclusion. Only one study measured agitation after the intervention finished, and did not show effects at 1-week and 4-week follow-up. Reference Kolanowski, Litaker, Buettner, Moeller and Costa24

Although activities in care homes reduced levels of agitation significantly while in place, there is no evidence regarding longer-term effect, and it is unclear whether individualising activities further reduces agitation. There is no evidence for activities in severe agitation or outside care homes.

Fig. 1 Study search profile (CEBM, Centre for Evidence-Based Medicine; RCT, randomised controlled trial).

Music therapy. Three RCTs, all in care homes, evaluated music therapy by trained therapists using a specific protocol - typically involving warming up with a well-known song, listening to and then joining in with the music. Reference Lin, Chu, Yang, Chen, Chen and Chang28-Reference Cooke, Moyle, Shum, Harrison and Murfield30 The largest study, which included participants irrespective of agitation level, found music therapy twice a week for 6 weeks was effective compared with the usual care group. Reference Lin, Chu, Yang, Chen, Chen and Chang28 A second study found a significant effect in comparison with a reading group, Reference Cooke, Moyle, Shum, Harrison and Murfield30 and the third found a borderline significant effect. Reference Sung, Lee, Li and Watson29 Reduction in symptoms of agitation was immediate (SES = 0.5-0.9). There is little evidence longer-term, and no evidence for people with severe agitation or outside care homes.

Sensory interventions

Five RCTs of sensory interventions, all in care homes, targeted perceived understimulation of people with dementia. Some focused on touch, such as massage; others were multisensory interventions of tactile, light and auditory stimulation, such as Snoezelen therapy. Reference Lin, Yang, Kao, Wu, Tang and Lin22,Reference Hawranik, Johnston and Deatrich31-Reference Van Weert, van Dulmen, Spreeuwenberg, Ribbe and Bensing34 Studies comparing touch found a significant improvement in symptomatic and clinically significant agitation compared with usual care. Reference Lin, Yang, Kao, Wu, Tang and Lin22,Reference Van Weert, van Dulmen, Spreeuwenberg, Ribbe and Bensing34 We report three ‘therapeutic touch’ studies; defined as a healing-based touch intervention focusing on the whole person. Reference Hawranik, Johnston and Deatrich31-Reference Woods, Beck and Sinha33 Despite therapeutic touch being efficacious in before-and-after analyses, in between-group analyses therapeutic touch tended towards being less efficacious than ordinary massage or usual treatment. Sensory interventions significantly improved symptomatic agitation and clinically significant agitation during the intervention, but therapeutic touch did not demonstrate added advantage, and there is insufficient evidence about long-term effects or in settings outside care homes.

Working through care-home staff

Person-centred care, communication skills training and dementia care mapping all seek to change the caregiver’s perspective, communication with and thoughts about people with dementia, encouraging the caregiver to see and treat them as individuals rather than being task-focused. Training paid caregivers in these techniques was investigated in five RCTs. Reference Chenoweth, King, Jeon, Brodaty, Stein-Parbury and Norman35-Reference Sloane, Hoeffer, Mitchell, McKenzie, Barrick and Rader39 All interventions included supervision during training and implementation.

Person-centred care. One high-quality study of person-centred care training found severe agitation significantly improved during the intervention and 8 weeks later. Reference Chenoweth, King, Jeon, Brodaty, Stein-Parbury and Norman35 Two studies of improving communication skills or person-centred care for participants with symptomatic agitation found significant improvements compared with the control group during the intervention, Reference McCallion, Toseland and Freeman37,Reference McCallion, Toseland, Lacey and Banks38 and up to 6 months afterwards. Reference McCallion, Toseland and Freeman37 A large study including participants without high agitation levels found agitation improved significantly during 8 weeks of person-centred care training and 20 weeks later. Reference Deudon, Maubourguet, Gervais, Leone, Brocker and Carcaillon36 One small study, where participants’ agitation levels were unspecified, showed immediate improvement in agitation during bathing compared with the control group. Reference Sloane, Hoeffer, Mitchell, McKenzie, Barrick and Rader39

Dementia care mapping. One large, high-quality care home study evaluated dementia care mapping. The researchers observed and assessed each resident’s behaviour, factors improving well-being and potential triggers; explained the results to caregivers, and supported proposed change implementation. Severe agitation decreased during the intervention and 4 months afterwards. Reference Chenoweth, King, Jeon, Brodaty, Stein-Parbury and Norman35

Effect sizes. Training paid care-home staff in communication skills, person-centred care or dementia care mapping with supervision during implementation was significantly effective for symptomatic and severe agitation immediately (SES = 0.3-1.8) and for up to 6 months (SES = 0.2-2.2). There was no evidence in other settings.

Interventions without evidence of efficacy

Working with the person with dementia

Light therapy. Light therapy hypothetically reduces agitation through manipulating circadian rhythms, typically by 30-60 min daily bright light exposure. We included three RCTs, all in care homes. Reference Ancoli-Israel, Martin, Gehrman, Shochat, Corey-Bloom and Marler40-Reference Dowling, Graf, Hubbard and Luxenberg42 Among participants with some or significant agitation, light therapy either increased agitation or did not improve it. The SES was 0.2 (for improvement) to 4.0 (for worsening symptoms) compared with the control group. There is therefore no evidence that light therapy reduces symptomatic or severe agitation in care homes and it may worsen it.

Aromatherapy. The two RCTs of aromatherapy both took place in care homes. Reference Ballard, O'Brien, Reichelt and Perry43,Reference Burns, Perry, Holmes, Francis, Morris and Howes44 One large, high-quality blinded study found no immediate or long-term improvement relative to the control group for participants with severe agitation. Reference Burns, Perry, Holmes, Francis, Morris and Howes44 The other, non-blinded, study found significant improvement compared with the control group. Reference Ballard, O'Brien, Reichelt and Perry43 When assessors are masked to the intervention, aromatherapy has not been shown to reduce agitation in care homes.

Training family caregivers in BMT. Two high-quality studies found no immediate or longer-term effect (at 3 months, 6 months or 12 months) of either four or eleven sessions training family caregivers in BMT for severe or symptomatic agitation in people with dementia living at home. Reference Gormley, Lyons and Howard45,Reference Teri, Logsdon, Peskind, Raskind, Weiner and Tractenberg46 Two studies training family caregivers in CBT for people with severe agitation also found no improvement compared with controls. Reference Wright, Litaker, Laraia and DeAndrade47,Reference Huang, Shyu, Chen, Chen and Lin48 There is thus high-quality evidence that teaching family caregivers BMT or CBT is ineffective for severe agitation, but insufficient evidence to draw conclusions regarding symptomatic agitation.

Interventions with insufficient evidence

For the following interventions there was insufficient evidence to make a definitive recommendation.

Exercise

There is no evidence that exercise is effective. The one sufficiently sized exercise RCT was conducted in a care home and found no effect on agitation levels either immediately or 7 weeks later.

Training caregivers without supervision

Training in communication skills and person-centred care without supervision was ineffective. Reference Magai, Cohen and Gomberg49,Reference Finnema, Droes, Ettema, Ooms, Ader and Ribbe50

Other interventions

One study found that simulated presence therapy - playing a recording mimicking a telephone conversation with a relative when the participant was agitated - was not effective. Reference Camberg, Woods, Ooi, Hurley, Volicer and Ashley51 One study testing a mixed psychosocial intervention, including massage and promoting residents’ activities of daily living skills, did not find agitation improved significantly compared with the control group. Reference Beck, Vogelpohl, Rasin, Uriri, O'Sullivan and Walls52

Standardised effect sizes

Figure 2 illustrates the effect of person-centred care, communication, dementia care mapping, music therapy and activities in reducing agitation. Long-term effects (in months) of changing the way caregivers interact with residents are at least as good as the short-term effects. Reference Chenoweth, King, Jeon, Brodaty, Stein-Parbury and Norman35,Reference McCallion, Toseland, Lacey and Banks38

Discussion

This is the first up-to-date systematic review to focus on agitation. It uniquely analyses whether the intervention was potentially preventive, by reducing mean levels of agitation symptoms including those not clinically significant at baseline or managed clinically significant agitation; whether effects were observed only while the intervention was in place or lasted longer; and the settings in which the intervention had been shown to be effective: the community or in care homes.

Effective interventions

Effective interventions seem to work through care staff, particularly in the long term. There is convincing evidence that when implementation is supervised, interventions that aim to communicate with people with dementia, helping staff to understand and fulfil their wishes, reduce symptomatic and severe agitation during the intervention and for 3-6 months afterwards. This suggests that training paid caregivers in communication, person-centred care skills or dementia care mapping are clinically important interventions, as shown by a 30% decrease in agitation Reference Ballard, O'Brien, Reichelt and Perry43 or a standardised effect size of 0.2, which is clinically small, 0.5 medium and 0.8 large. Reference Long53

Sensory interventions significantly improved agitation of all severities while in place. Therapeutic touch had no added advantage. We also found replicated, good-quality evidence that activities and music therapy by protocol reduce overall and symptomatic agitation in care homes while in place. Although we were surprised that individualised activities were no more effective than prescribed activities, the low numbers in the activity intervention groups may suggest that it was only those who were particularly suited to the activity who participated. There is no evidence for severe agitation. Theory-based activities (neurodevelopmental and Montessori) were no more effective than other pleasant activities.

Other interventions

Light therapy does not appear to be effective and may be harmful. Non-blinded interventions with aromatherapy appeared effective, possibly owing to rater bias, but masked raters do not find it effective. Training family caregivers in BMT and CBT interventions for the person with dementia was not effective. Learning complex theories and skills and maintaining fidelity to an intervention may be almost impossible to combine with looking after a family member with dementia and agitation on a 24-hour basis.

Strengths and weaknesses of the study

This is an exhaustive systematic review; two raters independently evaluated studies to ensure reliability in study inclusion and quality ratings. We searched all health and social sciences databases, translated non-English publications, reduced publication bias by searching the grey literature and asking experts about other studies, then repeated our searches. Some interventions were multicomponent and we made judgements about which category they belonged in and described them in the text. Most interventions had been tried only in care homes and we do not know their effect or practicality in people’s own homes where most people with dementia live. Although we excluded interventions in which all participants received medication, we cannot assess if medication use was uneven in different arms. Most studies included participants with any dementia and we cannot comment on the effect of interventions on different dementia subtypes.

Fig. 2 Standardised effect size and 95% confidence intervals where calculable of randomised controlled trials compared with controls for each reported outcome immediately and in the longer term.

Studies were heterogeneous in both intervention and measuring effects. This meant we were unable to meta-analyse and our conclusions are mostly based on a qualitative synthesis. Many studies were underpowered, possibly because residents were unwilling or unable to participate, or of low quality and therefore excluded. There were only eight level 1 studies and this is not evidence of lack of efficacy; there were several interventions with insufficient evidence to draw conclusions. Several interventions were implemented differently to usual practice and this may have altered the effect, for example in dementia care mapping. Reference Chenoweth, King, Jeon, Brodaty, Stein-Parbury and Norman35 Finally, although most studies used the CMAI many did not, and the definition of agitation varied between studies.

Other research

Early studies did not have the opportunity to use valid instruments for agitation; these now exist but may vary in their sensitivity to detect change. Differences in effect sizes between study results may therefore sometimes be due to instrument difference. Thus although our study’s strength is the literature integration, it underlines how much more work is needed. There are some RCTs currently in progress which should add to the evidence base. A recent study, considering overall neuropsychiatric symptoms (in contrast to our review specifically about agitation) found working with family caregivers to be effective, and it would be useful to examine which symptoms contributed to this effect and if it were mood rather than agitation. Reference Brodaty and Arasaratnam8

Study implications

Although agitation in dementia has been regarded as due to brain changes, our findings suggest agitation also arises from lack of understanding or unmet needs in someone whose dementia makes them unable to explain or understand this. This is in line with the need-driven, dementia-compromised behaviour theory of Algase et al, Reference Algase, Beck, Kolanowski, Whall, Berent and Richards54 and the hypothesis of Kitwood & Bredin that behaviours arise from need and occur when care is task-driven not person-centred (relevant to all neuropsychiatric symptoms). Reference Kitwood and Bredin55 Our findings suggest clinicians should stop considering agitation as an entity but instead often as a symptom of lack of understanding or unmet need that the person with dementia is unable to explain or understand. This may be physical discomfort or need for stimulation, emotional comfort or communication.

Future research

More evidence is required about implementing group activities in care homes over longer periods to prevent agitation. We recommend the development and evaluation of a manual-based training for staff in care homes employing interventions with evidence for efficacy, to allow translation to different settings. We suggest these interventions should focus on changing culture to implement programmes permanently. In general it seems that there is no evidence about settings outside care homes. The lack of effective interventions, despite 70-80% of people with dementia living at home and the potential of interventions to delay care home admission, suggests further research should start from qualitative interviews considering how agitation is experienced by people with dementia living at home, and how their families manage. This, together with synthesised evidence from other settings, could help in the development of a pilot intervention. Our review may suggest that it should have elements of sensory stimulation (including music), activities and teaching the family caregiver communication skills, to change themselves rather than the person with dementia.

Acknowledgements

We wish to thank Shirley Nurock, dementia family carer, for her thoughts and contributions.

Footnotes

This article presents independent research commissioned by the UK National Institute for Health Research (NIHR) Health Technology Assessment Programme: HTA 10/43/01. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA Programme, NIHR, the National Health Service or the Department of Health. The study was sponsored by University College London. Neither funders nor sponsors had a role in the study design and the collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication. The researchers were independent from funders and sponsors.

Declaration of interest

None.

References

1 Ryu, SH, Katona, C, Rive, B, Livingston, G. Persistence of and changes in neuropsychiatric symptoms in Alzheimer disease over 6 months – the LASERAD study. Am J Geriatr Psychiatry 2005; 13: 976–83.Google ScholarPubMed
2 Savva, GM, Zaccai, J, Matthews, FE, Davidson, JE, McKeith, I, Brayne, C, et al. Prevalence, correlates and course of behavioural and psychological symptoms of dementia in the population. Br J Psychiatry 2009; 194: 212–9.CrossRefGoogle ScholarPubMed
3 Wetzels, RB, Zuidema, SU, de Jonghe, JFM, Verhey, FRJ, Koopmans, RTCM. Determinants of quality of life in nursing home residents with dementia. Dementia and Geriatric Cognitive Disorders 2010; 29: 189–97.CrossRefGoogle ScholarPubMed
4 Draper, B, Snowdon, J, Meares, S, Turner, J, Gonski, P, McMinn, B, et al. Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior. Int Psychogeriatr 2000; 12: 333–44.CrossRefGoogle ScholarPubMed
5 Morris, LW, Morris, RG, Britton, PG. The relationship between marital intimacy, perceived strain and depression in spouse caregivers of dementia sufferers. Br J Med Psychol 1988; 61: 231–6.CrossRefGoogle ScholarPubMed
6 Livingston, G, Johnston, K, Katona, C, Paton, J, Lyketsos, CG. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry 2005; 162: 19962021.CrossRefGoogle ScholarPubMed
7 National Institute for Clinical Excellence, Social Care Institute for Excellence. Dementia: Supporting People with Dementia and Their Carers in Health and Social Care. NICE/SCIE, 2006.Google Scholar
8 Brodaty, H, Arasaratnam, C. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry 2012; 169: 946–53.CrossRefGoogle ScholarPubMed
9 Kong, EH, Evans, LK, Guevara, JP. Nonpharmacological intervention for agitation in dementia: a systematic review and meta-analysis. Aging Ment Health 2009; 13: 512–20.CrossRefGoogle ScholarPubMed
10 Bierman, EJ, Comijs, HC, Gundy, CM, Sonnenberg, C, Jonker, C, Beekman, AT. The effect of chronic benzodiazepine use on cognitive functioning in older persons: good, bad or indifferent? Int J Geriatr Psychiatry 2007; 22: 1194–200.CrossRefGoogle ScholarPubMed
11 Maher, AR, Maglione, M, Bagley, S, Suttorp, M, Hu, JH, Ewing, B, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis. JAMA 2011; 306: 1359–69.CrossRefGoogle ScholarPubMed
12 Porsteinsson, AP, Drye, LT, Pollock, BG, Devanand, DP, Frangakis, C, Ismail, Z, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA 2014; 311: 682–91.CrossRefGoogle ScholarPubMed
13 Howard, RJ, Juszczak, E, Ballard, CG, Bentham, P, Brown, RG, Bullock, R, et al. Donepezil for the treatment of agitation in Alzheimer's disease. N Engl J Med 2007; 357: 1382–92.CrossRefGoogle ScholarPubMed
14 Fox, C, Crugel, M, Maidment, I, Auestad, BH, Coulton, S, Treloar, A, et al. Efficacy of memantine for agitation in Alzheimer's dementia: a randomised double-blind placebo controlled trial. PLoS One 2012; 7: e35185.CrossRefGoogle ScholarPubMed
15 Banerjee, S, Hellier, J, Dewey, M, Romeo, R, Ballard, C, Baldwin, R, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378: 403–11.CrossRefGoogle ScholarPubMed
16 Husebo, BS, Ballard, C, Sandvik, R, Nilsen, OB, Aarsland, D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 2011; 343: d4065.CrossRefGoogle ScholarPubMed
17 Livingston, G, Kelly, L, Lewis-Holmes, E, Baio, G, Morris, S, Patel, N, et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technol Assess 2014; 18: 1226, v–vi.CrossRefGoogle ScholarPubMed
18 Cohen-Mansfield, J, Billig, N. Agitated behaviors in the elderly. I. A conceptual review. J Am Geriatr Soc 1986; 34: 711–21.CrossRefGoogle ScholarPubMed
19 Raglio, A, Bellelli, G, Traficante, D, Gianotti, M, Ubezio, MC, Villani, D, et al. Efficacy of music therapy in the treatment of behavioral and psychiatric symptoms of dementia. Alzheimer Dis Assoc Disord 2008; 22: 158–62.CrossRefGoogle ScholarPubMed
20 Cohen-Mansfield, J, Marx, MS, Dakheel-Ali, M, Regier, NG, Thein, K, Freedman, L. Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli? J Am Geriatr Soc 2010; 58: 1459–64.CrossRefGoogle ScholarPubMed
21 Hedges, L. Distribution theory for Glass's estimator of effect size and related estimators. J Educ Behav Stat 1981; 6: 107–28.Google Scholar
22 Lin, LC, Yang, MH, Kao, CC, Wu, SC, Tang, SH, Lin, JG. Using acupressure and Montessori-based activities to decrease agitation for residents with dementia: a cross-over trial. J Am Geriatr Soc 2009; 57: 1022–9.CrossRefGoogle ScholarPubMed
23 Buettner, LL, Ferrario, J. Therapeutic recreation-nursing team: a therapeutic intervention for nursing home residents with dementia. Ann Therap Rec 1997; 7: 21.Google Scholar
24 Kolanowski, A, Litaker, M, Buettner, L, Moeller, J, Costa, PT. A randomized clinical trial of theory-based activities for the behavioral symptoms of dementia in nursing home residents. J Am Geriatr Soc 2011; 59: 1032–41.CrossRefGoogle ScholarPubMed
25 Kovach, C, Cashin, S, Taneli, Y, Dohearty, P, Schlidt, A, Silva-Smith, A. Effects of the BACE intervention on agitation of demented residents in long-term care. Gerontologist 2003; 43: 233.Google Scholar
26 Cohen-Mansfield, J, Jensen, B. Do interventions bringing current self-care practices into greater correspondence with those performed premorbidly benefit the person with dementia? A pilot study. Am J Alzheimer Dis Other Demen 2006; 21: 312–7.CrossRefGoogle ScholarPubMed
27 Cohen-Mansfield, J, Parpura-Gill, A, Golander, H. Utilization of self-identity roles for designing interventions for persons with dementia. J Gerontol Ser B: Psychol SciSoc Sci 2006; 61B: 202–12.Google Scholar
28 Lin, Y, Chu, H, Yang, CY, Chen, CH, Chen, SG, Chang, HJ, et al. Effectiveness of group music intervention against agitated behavior in elderly persons with dementia. Int J Geriatr Psychiatry 2011; 26: 670–8.CrossRefGoogle ScholarPubMed
29 Sung, HC, Lee, WL, Li, TL, Watson, R. A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation of institutionalized older adults with dementia. Int J Geriatr Psychiatry 2012; 27: 621–7.CrossRefGoogle ScholarPubMed
30 Cooke, ML, Moyle, W, Shum, DH, Harrison, SD, Murfield, JE. A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia. Aging Ment Health 2010; 14: 905–16.CrossRefGoogle ScholarPubMed
31 Hawranik, P, Johnston, P, Deatrich, J. Therapeutic touch and agitation in individuals with Alzheimer's disease. West J Nurs Res 2008; 30: 417–34.CrossRefGoogle ScholarPubMed
32 Woods, DL, Craven, RF, Whitney, J. The effect of therapeutic touch on behavioral symptoms of persons with dementia. Altern Ther Health Med 2005; 11: 6674.Google ScholarPubMed
33 Woods, DL, Beck, C, Sinha, K. The effect of therapeutic touch on behavioral symptoms and cortisol in persons with dementia. Forsch Komplementmed 2009; 16: 181–9.CrossRefGoogle ScholarPubMed
34 Van Weert, JCM, van Dulmen, AM, Spreeuwenberg, PMM, Ribbe, MW, Bensing, JM. Behavioral and mood effects of Snoezelen integrated into 24-hour dementia care. J Am Geriatr Soc 2005; 53: 2433.CrossRefGoogle ScholarPubMed
35 Chenoweth, L, King, MT, Jeon, YH, Brodaty, H, Stein-Parbury, J, Norman, R, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol 2009; 8: 317–25.CrossRefGoogle ScholarPubMed
36 Deudon, A, Maubourguet, N, Gervais, X, Leone, E, Brocker, P, Carcaillon, L, et al. Non-pharmacological management of behavioural symptoms in nursing homes. Int J Geriatr Psychiatry 2009; 24: 1386–95.CrossRefGoogle ScholarPubMed
37 McCallion, P, Toseland, RW, Freeman, K. An evaluation of a Family Visit Education Program. J Am Geriatr Soc 1999; 47: 203–14.CrossRefGoogle ScholarPubMed
38 McCallion, P, Toseland, RW, Lacey, D, Banks, S. Educating nursing assistants to communicate more effectively with nursing home residents with dementia. Gerontologist 1999; 39: 546–58.CrossRefGoogle ScholarPubMed
39 Sloane, PD, Hoeffer, B, Mitchell, CM, McKenzie, DA, Barrick, AL, Rader, J, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J Am Geriatr Soc 2004; 52: 1795–804.CrossRefGoogle ScholarPubMed
40 Ancoli-Israel, S, Martin, JL, Gehrman, P, Shochat, T, Corey-Bloom, J, Marler, M, et al. Effect of light on agitation in institutionalized patients with severe Alzheimer disease. Am J Geriatr Psychiatry 2003; 11: 194203.CrossRefGoogle ScholarPubMed
41 Burns, A, Allen, H, Tomenson, B, Duignan, D, Byrne, J. Bright light therapy for agitation in dementia: a randomized controlled trial. Int Psychogeriatr 2009; 21: 711–21.CrossRefGoogle ScholarPubMed
42 Dowling, GA, Graf, CL, Hubbard, EM, Luxenberg, JS. Light treatment for neuropsychiatric behaviors in Alzheimer's Disease. West J Nurs Res 2007; 29: 961–75.CrossRefGoogle ScholarPubMed
43 Ballard, CG, O'Brien, JT, Reichelt, K, Perry, EK. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. J Clin Psychiatry 2002; 63: 553–8.CrossRefGoogle ScholarPubMed
44 Burns, A, Perry, E, Holmes, C, Francis, P, Morris, J, Howes, MJ, et al. A double-blind placebo-controlled randomized trial of Melissa officinalis oil and donepezil for the treatment of agitation in Alzheimer's disease. Dementia Geriatr Cogn Disord 2011; 31: 158–64.CrossRefGoogle ScholarPubMed
45 Gormley, N, Lyons, D, Howard, R. Behavioural management of aggression in dementia: a randomized controlled trial. Age Ageing 2001; 30: 141–5.CrossRefGoogle ScholarPubMed
46 Teri, L, Logsdon, RG, Peskind, E, Raskind, M, Weiner, MF, Tractenberg, RE, et al. Treatment of agitation in AD – a randomized, placebo-controlled clinical trial. Neurology 2000; 55: 1271–8.CrossRefGoogle Scholar
47 Wright, LK, Litaker, M, Laraia, MT, DeAndrade, S. Continuum of care for Alzheimer's disease: a nurse education and counseling program. Issues Ment Health Nurs 2001; 22: 231–52.CrossRefGoogle ScholarPubMed
48 Huang, HL, Shyu, YIL, Chen, MC, Chen, ST, Lin, LC. A pilot study on a home-based caregiver training program for improving caregiver self-efficacy and decreasing the behavioral problems of elders with dementia in Taiwan. Int J Geriatr Psychiatry 2003; 18: 337–45.CrossRefGoogle ScholarPubMed
49 Magai, C, Cohen, CI, Gomberg, D. Impact of training dementia caregivers in sensitivity to nonverbal emotion signals. Int Psychogeriatr 2002; 14: 2538.CrossRefGoogle ScholarPubMed
50 Finnema, E, Droes, RM, Ettema, T, Ooms, M, Ader, H, Ribbe, M, et al. The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial. Int J Geriatr Psychiatry 2005; 20: 330–43.CrossRefGoogle ScholarPubMed
51 Camberg, L, Woods, P, Ooi, WL, Hurley, A, Volicer, L, Ashley, J, et al. Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease. J Am Geriatr Soc 1999; 47: 446–52.CrossRefGoogle ScholarPubMed
52 Beck, CK, Vogelpohl, TS, Rasin, JH, Uriri, JT, O'Sullivan, P, Walls, R, et al. Effects of behavioral interventions on disruptive behavior and affect in demented nursing home residents. Nurs Res 2002; 51: 219–28.CrossRefGoogle ScholarPubMed
53 Long, PW. When is a Difference Between Two Groups Significant? Internet Mental Health, 2011 (http://www.mentalhealth.com/dis-rs/rs-effect_size.html).Google Scholar
54 Algase, DL, Beck, C, Kolanowski, A, Whall, A, Berent, S, Richards, K, et al. Need-driven dementia-compromised behavior: an alternative view of disruptive behavior. Am J Alzheimers Dis Other Demen 1996; 11: 10–9.Google Scholar
55 Kitwood, T, Bredin, K. Towards a theory of dementia care: personhood and well-being. Ageing Soc 1992; 12: 269–87.CrossRefGoogle ScholarPubMed
56 Remington, R. Calming music and hand massage with agitated elderly. Nurs Res 2002; 51: 317–23.CrossRefGoogle ScholarPubMed
57 Weiner, MF, Tractenberg, RE, Sano, M, Logsdon, R, Teri, L, Galasko, D, et al. No long-term effect of behavioral treatment on psychotropic drug use for agitation in Alzheimer's disease patients. J Geriatr Psychiatry Neurol 2002; 15: 95–8.CrossRefGoogle ScholarPubMed
58 Eggermont, LH, Blankevoort, CG, Scherder, EJ. Walking and night-time restlessness in mild-to-moderate dementia: a randomized controlled trial. Age Ageing 2010; 39: 746–9.CrossRefGoogle ScholarPubMed
59 Hong, GR. [Effects of multisensory stimulation using familiarity: persons with dementia in long-term care facility in Korea]. J Korean Acad Nurs 2011; 41: 528–38.CrossRefGoogle Scholar
Figure 0

Fig. 1 Study search profile (CEBM, Centre for Evidence-Based Medicine; RCT, randomised controlled trial).

Figure 1

Fig. 2 Standardised effect size and 95% confidence intervals where calculable of randomised controlled trials compared with controls for each reported outcome immediately and in the longer term.

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