This review concluded that there was limited evidence on the efficacy of emotion-oriented, behavioural/environmental approaches and sensory stimulation for treating neuropsychiatric symptoms in patients with moderately severe to severe dementia. These conclusions were supported by the results, but should be interpreted with caution due to the possibility of missing studies and the very small number of studies for each intervention.

To evaluate studies on non-pharmacological interventions for treating neuropsychiatric symptoms in advanced dementia.

MEDLINE, CINAHL, PsycINFO, EMBASE, Dissertations International and Cochrane Database of Systematic Reviews were searched for published peer-reviewed English-language studies from 1974 to September 2008. Search terms were reported. Reference lists of systematic reviews were screened.

Studies of non-pharmacological interventions in patients with severe or very severe dementia that reported measures of neuropsychiatric symptoms as the primary outcome were eligible for inclusion. Specific definitions of severe dementia had to be adhered to (full details reported in the review). Studies with a combined pharmacological and non-pharmacological intervention or that assessed the effects of electrical stimulation were excluded. Studies that focused on palliative or end-of-life care or on sleep dysfunction or architecture in dementia were excluded. Case reports, observational studies and qualitative studies were excluded.

Included patients had mild to severe dementia. Studies were conducted in nursing homes, geriatric psychiatry facility, long-term care facilities, psychogeriatric institutions/facilities and day hospitals in Europe, USA, Australia, Canada, Hong Kong and Japan. Interventions covered emotion-oriented treatments, simulated presence, behavioural and environmental treatments and sensory stimulation-oriented approaches (aromatherapy, bright light therapy, music therapy, movement therapy, multi-sensory stimulation, touch therapy and balancing arousal). A variety of neuropsychiatric symptoms were assessed using a variety of measurement scales. Follow-up duration ranged from two weeks to 12 months (where reported).

The authors did not state how many reviewers assessed studies for inclusion.

Studies were graded as high, moderate or low/major flaws based on sample size calculation, control for confounding, equivalence of intervention groups, description of methods and validity of conclusions (attrition, use of validated outcome, blinding).

The authors did not state how many reviewers performed the quality assessment.

The authors did not state how data were extracted from the studies.

A narrative synthesis was presented.

Twenty-two studies (number of participants unclear) were included in the review: 13 randomised controlled trials (RCTs); three non-randomised comparative studies; and six single-group studies with repeated measures. Six studies were judged to be high quality, seven were moderate quality and eight were low quality.

Emotion-oriented approaches: (four RCTs)

Two studies reported significant beneficial effects of the intervention. Two studies reported no significant differences compared to usual care.

Behavioural/environmental approaches: (two non-randomised study, one single-group study)

All three studies reported significant beneficial effects of special care units.

Sensory stimulation: (nine RCTs, one non-randomised study, five single-group studies)

Three studies of moderate to high quality reported significant beneficial effects of aromatherapy compared to control. One low-quality study found no significant within-group differences. Two low-quality studies reported significant beneficial effects of bright light therapy. Two low-quality studies assessed movement therapy and both reported some beneficial effects of the intervention. Three RCTs reported significant beneficial effects of music therapy on symptoms. Two RCTs assessed multi-sensory stimulation: one reported significant beneficial effects and the other found significant beneficial effects when results were stratified by dementia severity. One single-group study reported significant beneficial effects of touch therapy. One RCT reported significant beneficial effects of a balancing arousal intervention.

There was limited moderate- to high-quality evidence on the efficacy of emotion-oriented behavioural/environmental approaches and sensory stimulation for treating neuropsychiatric symptoms in patients with moderately severe to severe dementia.

The review addressed a clear question and inclusion criteria were defined, although these were not adhered to in the review as studies of patients with mild dementia were included due to the small number of studies conducted in patients with severe dementia. The literature search was appropriate for published studies. The restriction to published English-language studies meant that there was a possibility of language and publication biases. Details of the review process were not reported and so it was not possible to determine whether appropriate steps were taken to minimise bias. Study quality was assessed using some relevant criteria. Results were presented only as summary gradings with no detail on individual items. A narrative synthesis was appropriate given the differences between studies.

The authors conclusions were supported by the results, but should be interpreted with some caution due to the possibility of missing studies and the very small number of studies for each intervention.

Practice: The authors did not state any implications for practice.

Research: The authors stated that future studies should be specifically designed to explore the stage-specific efficacy of non-pharmacological therapies for patients with advanced dementia. Aresa of particular need include movement-based therapies, hand-on (touch) therapies and interventions that could be provided during personal care routines.

Blaustein Postdoctoral Fellowship in Psychiatric Nursing of the Johns Hopkins University School of Nursing; Johns Hopkins Medical Institution Department of Psychiatry.

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.