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The effects of emotion-oriented approaches in the care for persons suffering from dementia: a review of the literature |
Finnema E, Droes R M, Ribbe M, Van Tilburg W |
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Authors' objectives To assess the effectiveness of emotion-orientated approaches in the care of people with dementia.
Searching MEDLINE, PsycLIT, EMBASE, Sociofile, and Current Contents were searched from 1990 to 1999 using the terms 'dementia' and 'Alzheimer's disease' linked separately to the following terms: 'emotion-orientated', 'validation (therapy)', 'sensory integration/sensory stimulation/snoezelen/multi-sensory environment/multi-sensory enhancement', 'stimulated presence therapy' and ' reminiscence (therapy)/life review'. References from identified studies were examined, and additional studies by Droes (see Other Publications of Related Interest nos.2-3) were used to provide information for the period 1970 to 1990. Articles published in English, French, German or Dutch were eligible.
Study selection Study designs of evaluations included in the reviewIntervention studies that described the intervention, design, measuring instrument and results were eligible.
Specific interventions included in the reviewEmotion-orientated approaches used in 24-hour care, as distinguished by the American Psychiatric Association, were eligible (see Other Publications of Related Interest no.1). Supportive psychotherapy was excluded. The following approaches were included: validation; sensory stimulation and integration; simulated presence therapy and video respite; and reminiscence.
Participants included in the reviewPeople with dementia, specifically Alzheimer's disease, were eligible. Participants were patients with mild to severe dementia recruited from residential homes, nursing homes, day centres, psychiatric wards, community hospitals, community day hospitals, geriatric hospitals and the community.
Outcomes assessed in the reviewThe inclusion criteria were not defined in terms of the outcome. Specific patient-related outcomes assessed in the review included: communication (Holden Communication Scale, sound recordings); mood (BMD-scale); behaviour including outcomes related to adapting to illness and institutionalisation (CAPE Behaviour Rating Scale, MACC Behavioural Adjustment Scale, REHAB Interact, GIP MBR-scale based on video records,); cognition, mood and social contact (BPS, MMSE, CAS); mental status (MMSE); functional status (Katz Index of ADL Evaluation Form, PSBADL); depression (Modified Beck Depression Inventory, Cornell Scale for depression in dementia); psychosocial functioning (MOSES and MDS +); agitation (CMAI); positive (non) verbal and non interactive behaviour (GIPB); adaptive functioning (short form of Adaptive Behaviour Scale); psychopharmacological drugs and physical restraints; comments about therapy; well-being (Dementia Care Mapping); and social behaviour (RMBPC). The following nursing assistant outcomes were assessed: attitude and behaviour towards residents assessed using the Questionnaire Verpoort; and general mental and physical health (GHQ, Dutch work satisfaction scale, Dutch organization and stress scale, observation). The family caregiver-related outcomes assessed were mood (relatives mood scale) and stress (relatives stress scale).
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.
Assessment of study quality No formal assessment of validity was undertaken.
Data extraction The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction. The following data were extracted: number and composition of participants; sample size; setting; study design; effect variables; content of intervention; measuring instrument; statistical analysis; and results.
Methods of synthesis How were the studies combined?The studies were grouped according to the type of approach and combined in a narrative review.
How were differences between studies investigated?Some potential sources of differences were discussed.
Results of the review Twenty-three studies were included: these comprised parallel group and crossover randomised trials, controlled trials with a non-equivalent control group, pre-test post-test studies, case-series studies, time-series designs and qualitative studies. It was not possible to estimate the total number of patients included.
Many of the studies had methodological problems which limited the evidence.
Problems included: non-comparability of control and experimental groups on crucial aspects; lack of validated measuring instruments and objective evaluators; studies were conducted among mixed patient groups with different types of dementia; and the diagnosis of patients was frequently unclear.
Validation (5 studies): the evidence was limited. Most of the studies had methodological problems. Studies differed in the way validation was applied, the research method, the population studied, the effect variables and measuring instruments, and were consequently difficult to compare.
Snoezelen and sensory integration: 5 studies of snoezelen, and 2 studies in which the intervention included sensory stimulation, were included. Studies generally reported positive effects of the intervention on mood and behaviour, but methodological problems weakened the strength of the evidence. Like the validation studies, these studies were also difficult to compare.
Simulated presence and video respite therapy (4 studies): these approaches are relatively new and have not been sufficiently examined to allow firm conclusions.
Reminiscence (4 studies): studies mainly reported positive results but were subject to methodological limitations; consequently, results were difficult to generalise.
Authors' conclusions Despite the limited cogency of the identified studies, results from emotion-orientated approaches are promising. Emotion-orientated care approaches offer the opportunity to tailor the care to individual needs of dementing elderly, and can be complemented with other psychosocial approaches when necessary. Scientific research can contribute by examining which emotion-orientated approaches, possibly in combination with each other or with psychosocial therapies, effect an increase in well-being and in which patients they improve functioning.
CRD commentary The aims were stated, and the inclusion criteria were defined in terms of participants, intervention and study design. Several relevant potential sources of studies were searched and studies in any of four European languages were eligible. No attempt was made to locate unpublished materials, thus raising the possibility of publication bias. Methods used to select studies were not described. Some aspects of validity were discussed though no formal assessment of validity was undertaken. Some relevant details of the primary studies were presented in tabular format, but no details were given of methods used to extract data or the diagnostic criteria for dementia. Given the many differences between studies, a narrative review was appropriate. However, in combining the studies, attention was not drawn to better sources of evidence. This was especially a problem as four of the studies were randomised controlled trials, while the other studies were of a less valid design. The results of the randomised controlled trials were not highlighted.
Given the apparent methodological limitations of the primary studies, caution should be applied when considering the conclusions.
Implications of the review for practice and research Practice: The authors did not report any implications for practice.
Research: The authors state that future research should examine which of the emotion-orientated approaches effect an increase in the well-being of patients with dementia.
Bibliographic details Finnema E, Droes R M, Ribbe M, Van Tilburg W. The effects of emotion-oriented approaches in the care for persons suffering from dementia: a review of the literature. International Journal of Geriatric Psychiatry 2000; 15(2): 141-161 Other publications of related interest 1. American Psychiatric Association. Practice guidelines for the treatment of patients with Alzheimer's disease and other dementias of later life. Am J Psychiatry 1997;154 Suppl 5:1-39. 2. Droes RM. In: Beweging: over psychosociale hulpverlening aan demente ouderen. Utrecht: De Tijdstroom; 1991. 3. Droes RM. In: Movement Therapy across the Life-Span. Vermeer A, Bosscher RJ, Broadhead GD, editors. Amsterdam: VU University Press; 1997. p. 337-80.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Alzheimer Disease /psychology /therapy; Clinical Trials as Topic; Combined Modality Therapy; Emotions; Geriatric Assessment; Homes for the Aged; Humans; Nursing Homes; Psychotherapy; Social Behavior; Treatment Outcome AccessionNumber 12000000541 Date bibliographic record published 31/01/2002 Date abstract record published 31/01/2002 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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