psychosocial interventions for people with a milder dementing illness: a systematic review

INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

Psychosocial interventions for people with a milder dementing illness:

a systematic review

Jane Bates BA RMN

Day Hospital Manager, Vale Day Hospital, Abingdon Mental Health Centre, Abingdon, Oxfordshire, UK

Jonathan Boote MA MSc PhD

Research Officer, Clinical Effectiveness Directorate, Sheffield Care Trust; and Honorary Research Fellow, School of Health and

Related Research, University of Sheffield, Sheffield, UK

and Catherine Beverley BSc MSc MCLIP

Systematic Reviews Information Officer, School of Health and Related Research, University of Sheffield, Sheffield, UK

Submitted for publication 24 April 2003

Accepted for publication 30 October 2003

Correspondence:

Jonathan Boote,

School of Health and Related Research,

University of Sheffield,

Sheffield,

South Yorkshire S1 4DA,

UK.

E-mail: [email protected]

BATES J . , BOOTE J. & BEVERLEY C. (2004)BATES J. , BOOTE J. & BEVERLEY C. (2004) Journal of Advanced Nursing 45(6),

644–658

Psychosocial interventions for people with a milder dementing illness: a systematic review

Introduction. Over the last three decades, interest has grown in the use of psycho-

social interventions for people with dementia. Empirical studies and systematic re-

views have been undertaken on a range of such interventions to examine their

effectiveness. However, little account has been taken of the appropriateness of

psychosocial interventions for people in different stages of the illness. This raises

important questions about the degree to which the research evidence can be gen-

eralized for people in the milder and the more severe stages of dementia. This

systematic review was undertaken therefore to investigate the effectiveness of psy-

chosocial interventions for people with a milder dementing illness.

Methods. A comprehensive search was undertaken using all the major health care

databases, as well as various grey literature sources. For studies to be included in the

review, they must have investigated the effect of one or more psychosocial inter-

vention on people with a milder dementing illness, employing a controlled trial

design, and measuring outcomes such as cognitive ability, communication, func-

tional performance and well-being. Identified studies were critically appraised, and

where suitable for inclusion, data were extracted.

Results. Four studies met the final inclusion criteria for the review, and covered

three psychosocial interventions: reality orientation, procedural memory stimulation

and counselling. No evidence was found for the effectiveness of counselling and

procedural memory stimulation on the outcome measures used. However, some

evidence was found that reality orientation is effective in improving cognitive

ability, with a demonstrable long-term gain using follow-up data.

Conclusions. The review provides some evidence for the use of reality orientation

for people in the milder stages of dementia. However, due to the small sample sizes

in all the included studies, more research is needed into the effectiveness of psy-

chosocial interventions for this client group. Implications for nursing practice are

discussed, and recommendations for future research are set out.

644 � 2004 Blackwell Publishing Ltd

Keywords: nursing, dementia, psychosocial interventions, reality orientation,

counselling, procedural memory stimulation

Dementia: incidence, prevalence and treatment

Dementia is a progressive, degenerative disease characterized

by cognitive decline, impaired memory, thinking and beha-

viour. World-wide estimates of the number of dementia

sufferers vary from 15 to 18 million, and it is forecast that by

2025, 34 million people will have the disease, 71% of whom

will live in developing countries (Alzheimer’s Society 2003,

Eisai Alzheimer’s Worldwide 2003). The prevalence of

dementia increases with age. For example, Alzheimer’s

disease, the most common form of dementia, affects 5–10%

of all adults over 65, increasing to nearly 50% for those over

85 (Eisai Alzheimer’s Worldwide 2003). In the United

Kingdom (UK), approximately 600 000 people have demen-

tia, representing 5% of those aged 65 and over, rising to 20%

of those aged 80 and over. It is estimated that by 2026,

840 000 people in the UK will have dementia, rising to

1Æ2 million by 2050 (Department of Health 2001).

These statistics highlight the importance of establishing

the most clinical and cost-effective treatments for people

with dementia, especially because, as the population ages,

the incidence of the disease is likely to place an increasing

burden on health care resources (Eisai Alzheimer’s World-

wide 2003). Dementia treatment can be divided into two

main categories: (1) psychopharmacological therapy, under-

pinned by the biomedical model of care; and (2) non-

pharmacological, psychosocial and other alternative approa-

ches, reflecting a more holistic vision of ‘person-centred’

dementia care.

Pharmacological treatment includes drugs such as donepe-

zil and rivastigmine (acetylcholinesterase inhibitors), which

aim to alleviate symptoms in the mild and moderate stages of

the disease. Approximately 400 000 of the UK’s dementia

sufferers have Alzheimer’s disease and, of these, 250 000

have a dementia of a mild to moderate severity (National

Institute for Clinical Excellence 2001). These drugs have been

shown to have some effect on global outcome measures, but

not everyone appears to benefit. It has been found that

pharmacological treatment only postpones the onset of severe

impairment in Alzheimer’s disease and does not affect the

prognosis. Treatment may also be contraindicated because of

poor compliance with medication, or because of side-effects

such as nausea and vomiting (National Institute for Clinical

Excellence 2001).

That not everyone with dementia appears to benefit from

pharmacological treatment highlights the importance of alter-

native, non-pharmacological therapies such as reminiscence

and validation therapies, and reality orientation, which have

been increasingly researched over recent years. However,

findings tend not to be specific about when and to which clients

these therapies are best targeted: this is because many studies

have been undertaken with clients at varying stages of impair-

ment, and where findings have been aggregated. Brodaty (1999)

conjectures about ‘critical windows’ with regard to pharmaco-

logical interventions where treatment strategies stand a better

chance of success. Such critical windows are also likely to exist

for dementia sufferers being treated with targeted non-phar-

macological interventions (Moniz-Cook et al. 1998).

Psychosocial approaches to dementia care form an import-

ant part of modern-day non-pharmacological treatment. The

term ‘psychosocial’ implies human interactive behaviour

between therapist and client; examples of psychosocial

interventions include reality orientation, and reminiscence

and validation therapies. A psychosocial framework informs

such therapies, where the person with dementia is central to

and involved in their care. Kitwood (1997) firmly located the

discourse of dementia care and research within such a

framework, and discussed how early interventions provided

to people with dementia could prevent the development of a

‘malignant social psychology’. Clare (1999, p. 33) reinforces

this perspective by stating that, ‘from a psychosocial stand-

point, the aims of early intervention for the person with

dementia include optimizing functioning and well-being,

minimizing the risk of excessive disability’.

Psychosocial approaches to dementia care and the import-

ance of early intervention – as highlighted in the UK by the

National Service Framework for Older People (Department

of Health 2001) – raise important questions. Are appropriate

psychosocial interventions provided to people in the milder

stages of dementia? Are they effective on a range of key

outcomes? Are appropriate and effective psychosocial inter-

ventions implemented at an early enough stage to make a

difference to the person with dementia’s quality of life and

potentially that of their main carers?

A number of systematic reviews have been undertaken of

various individual psychosocial interventions (Koger &

Brotons 2002, Neal & Briggs 2002, Spector et al. 2002a,

2002b). However, although useful in synthesizing the litera-

ture, systematic reviews tend not to report findings that

distinguish between clients at various stages of dementia, thus

limiting their applicability to specific clinical settings (e.g.

assessment centres for people at the early stages of dementia).

Integrative literature reviews and meta-analyses Psychosocial interventions for people with milder dementing illness

� 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(6), 644–658 645

Due to the importance of intervening psychosocially at an

early stage, the need for comprehensive systematic review of

psychosocial interventions provided to people in the milder

stages of dementia was identified. By ‘milder’, we specifically

mean the ‘mild’ and the ‘mild to moderate’ stages of dementia.

The review

Scope and definitions

The main study question was: ‘Are psychosocial interven-

tions effective for people with a mild or a mild to moderate

dementing illness?’ It is important to define explicitly the

terms ‘mild and mild to moderate dementia’, ‘psychosocial’

and ‘psychosocial interventions’. In the absence of any

standardized and widely used definition, we define the terms

mild and mild to moderate dementia by scores on the Mini-

Mental State Examination (MMSE) (Folstein et al. 1975).

Although not without its critics, the MMSE has been widely

used as a dementia assessment instrument in both research

and clinical practice since its publication. For the purposes

of this review, a person has mild dementia if scoring 18–23

on the MMSE and mild to moderate dementia if scoring 15–

17. The remainder of the review will refer to the term

‘milder’ dementia to mean ‘mild and mild to moderate’

dementia.

The term ‘psychosocial’ is defined by the Oxford English

Dictionary (OED) as, ‘of or involving the influence of social

factors or human interactive behaviour’. This OED definition

was used to guide the review. We define a psychosocial

intervention as a therapeutic endeavour involving human

interactive behaviour between therapist(s) and client(s)

throughout the course of the intervention. Such an interven-

tion may include prosthetic memory aids as adjuncts.

However, where the prosthetic aid is the focus of the

intervention, rather than merely an adjunct, we did not

consider it a psychosocial intervention, using our adopted

definition.

Search strategy

A systematic review of the literature was undertaken using

methods described in the NHS Centre for Reviews and

Dissemination Report Number 4 (NHS Centre for Reviews

and Dissemination, 2001).

The search aimed to identify all literature relating to

psychosocial interventions for people with dementia.

Between April and June 2002, 15 major electronic databases

were searched and 10 grey literature sources were consulted

(see Appendix 1). A general Internet search using a standard

search engine (Google) was also performed, and reference

lists were hand-searched for additional references. Lead

researchers of current studies, as identified on the National

Research Register, were contacted to ascertain if a paper

relating to their study was due for publication during the

production of this review.

A combined free-text and thesaurus approach was adop-

ted. ‘Population’ search terms included: dement*, alzhei-

mer*, memory disorders, etc. ‘Intervention’ search terms

included: non-pharmacolog*, psychotherapy, psychosocial,

cognitive therap*, behavio(u)r* therap*, counselling, art

therapy, music therapy, writing therapy, dance therapy,

relax* therap*, humour*, laughter, fun, person cent*,

personhood, validation therap*, reminiscence therap*, mem-

ory stimulation, reality orientation, reality therapy, rehabil-

itation, reorientation, life memor*, life stor*, speech therap*,

language therap*, life style, exertion, fitness, exercise*,

sports, tai chi, aerobics, swim*, social environment, diet

therapy, alternative medicine, gingko, etc. A sample search

strategy is provided in Appendix 2. No date, language, study

or publication type restrictions were placed on the search,

except those imposed by the databases themselves.

Inclusion and exclusion criteria

Inclusion and exclusion criteria were developed to guide the

search strategy (see Table 1). The review focused on the most

common types of dementia (Alzheimer’s, vascular, fronto-

temporal and Lewy Body) that account for approximately

95% of all dementia types (Alzheimer’s Society 2003), and

excluded those less common dementia types (Parkinsons-

related dementia, Huntingdon’s, Creutzfeldt-Jakob disease,

Aids-related dementia and Korsakoff’s syndrome).

Appraisal of study quality and data extraction

The first two authors jointly reviewed the acquired literature

and assessed study quality. Disagreements were resolved

through discussion with the third author. Where clarification

was required on a specific paper, the named lead researcher

was contacted. Once agreement was reached on included

studies, the first two authors undertook data extraction

separately, and the second author checked the accuracy of all

data extractions.

Established checklists were consulted to guide the exam-

ination of study quality but none was deemed suitable for this

review, and a revised appraisal checklist was developed.

Methodological quality was considered on the bases of study

design, randomization, power calculation, blinding and

attrition. Data extraction forms were designed to extract

J. Bates et al.

646 � 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(6), 644–658

data relating to sample characteristics, country and care

settings, baseline MMSE scores, specifics of the intervention

and control group activity, outcome and outcome measures,

data collection points and key findings.

Results

Identifying included studies

The search yielded 3698 papers and 208 papers were

acquired. Of these, 151 were excluded. After critical apprai-

sal of the remainder, four papers were included and their data

were extracted. Excluded acquired studies, arranged both

thematically and alphabetically, are available on request from

the second author. A summary of included papers is

contained in Table 2.

Methodological quality

Methodological issues relating to the included studies are

outlined in Table 3. These issues were examined to determine

the extent to which study design and methods would be likely

to prevent systematic errors or bias.

Study design

The four studies employed the same design; a controlled

prospective treatment study, using one experimental group

that received the intervention, and one control group that did

not.

Selection bias

Only one included study made reference to the random

allocation of subjects (LaBarge et al. 1988). However, no

Table 1 Inclusion and exclusion criteria

Criteria Inclusion Exclusion

Population Adults with one of the following dementing

illnesses at a mild and mild to moderate stage:

1. Alzheimer’s

2. Vascular

3. Fronto-temporal (including Pick’s disease, semantic

dementia and primary progressive dysphasia)

4. Lewy Body

5. Early onset

6. Presenile

• Adults with the following dementing illnesses:

1. Parkinson-related

2. Huntington’s

3. Creutzfeldt-Jakob disease

4. Aids-related

5. Korsakoff’s syndrome

• Adults with moderate or severe dementia

• Adults with dementia and behavioural complica-

tions such as depression and aggression

Interventions 1. Psychosocial

2. Psychosocial in combination with pharmacological

1. Pharmacological solely

2. Pharmacological interventions for behavioural

complications with dementia, e.g. depression

3. Behavioural management interventions for adults

with dementia and behavioural complications

such as depression and aggression

4. Non-psychosocial

Outcomes and measures Outcomes and measures relating to the client:

1. Quality of life

2. Well-being

3. Cognitive ability

4. Mobility

5. Self-esteem

6. Memory

7. Communication

8. Adjustment

1. Cost-effectiveness measures

2. Outcomes relating to formal and informal carers

3. Measures that were used by carers to collect data

4. Measures that were used by researchers to collect

data about a patient from the caregiver

Study design and

publication type

1. Systematic reviews

2. Randomized controlled trials

3. Case-control studies

4. Cohort studies

5. Qualitative research

1. Editorials

2. Letters to journals

3. Viewpoint papers

4. Commentaries

5. Guidelines

6. Case study designs

7. Minor pieces of grey literature

Publication years Post 1966 Pre 1966

Language English Non-English



details were provided of the method by which randomization

was achieved. Random allocation to treatment groups was

inappropriate in the case of Zanetti et al.’s (1995) study be-

cause the controls were usually the ‘cognitively normal’

spouse of the patient in the experimental group.

Performance bias

As Spector et al. (2002a, p. 6) argue, any attempt to reduce

performance bias in the case of psychological interventions

is very difficult, if not impossible, to achieve: ‘with psy-

chological interventions, unlike drug trials, it is impossible

to blind patients and staff to treatment. Patients will often

be aware that they are being treated preferentially, staff

involved may have different expectations of treatment

groups, and independent assessors may be given clues from

patients during the assessments’. One included study (Za-

netti et al. 1995) made reference to efforts to reduce per-

formance bias by ensuring that the intervention was carried

out in a naturalistic setting, thus strengthening the ecologi-

cal validity of the findings. The extent that naturalistic set-

tings reduce performance bias is difficult to assess, however,

as this does not guarantee that participants were blinded to

the intervention.

Detection bias

Two of the included studies reported efforts to blind those

measuring outcomes (Zanetti et al. 1995, 1997). For exam-

ple, Zanetti et al. (1997) stated that, at baseline and post-test,

patients were assessed by a psychologist who was blinded to

the two study groups.

Sample sizes and statistical power

Sample sizes tended to be small, ranging from 19 (LaBarge

et al. 1988) to 28 (Zanetti et al. 1995). No included study

made reference to a power calculation, and whether the

included studies are sufficiently powered is open to question.

Table 2 Summary of included papers

Issue Breakdown Paper

Intervention Procedural memory stimulation Zanetti et al. (1997)

Counselling LaBarge et al. (1988)

Reality orientation Baldelli et al. (1993),

Zanetti et al. (1995)

Outcomes and measures Cognitive ability

• Mini-Mental State Examination (Folstein et al. 1975) Baldelli et al. (1993), Zanetti et al. (1995)

• Rey figure (recall) (Rey 1983) Zanetti et al. (1997)

• Logical memory (Spinller & Tognini 1987) Zanetti et al. (1997)

• Learning test (Spinller & Tognini 1987) Zanetti et al. (1997)

• Memory recall – animal naming (Rosen 1980) Zanetti et al. (1995)

• Word-stem completion (Graf et al. 1984) Zanetti et al. (1997)

Functional performance

• Activities of daily living (Stewart 1980) Baldelli et al. (1993)

• Skill learning (Perani et al. 1993) Zanetti et al. (1997)

• Digit span (Orsini et al. 1987) Zanetti et al. (1995)

• Orientation Scale for Geriatric Patients (Berg & Svensson 1980) Baldelli et al. (1993)

Well-being

• Wallace Self-Concept Scale (Wallace et al. 1984) LaBarge et al. (1988)

• Speilberger State-Trait Personality Inventory (Speilberger 1985) LaBarge et al. (1988)

• Geriatric Depression Scale (Yesavage et al. 1983) Baldelli et al. (1993), Zanetti et al. (1995)

Communication

• Verbal fluency (Novelli et al. 1986) Zanetti et al. (1995)

Setting (country) Italy Zanetti et al. (1995, 1997)

United States of America LaBarge et al. (1988)

Not stated (although Italy assumed) Baldelli et al. (1993)

Setting (care) Not stated LaBarge et al. (1988), Baldelli et al. (1993)

Day hospitals Zanetti et al. (1995, 1997)

Practitioner delivering Two rehabilitation therapists Zanetti et al. (1997)

intervention Occupational therapist Zanetti et al. (1995)

‘Doctoral-level counselling students’ LaBarge et al. (1988)

Not stated Baldelli et al. (1993)

J. Bates et al.


Attrition bias

One or more individuals withdrawing from a study examin-

ing the effectiveness of psychosocial interventions can affect

outcomes, due to the disruption of the group dynamic.

Zanetti et al. (1997) did not refer to an attrition rate, while

reported attrition rates varied. Baldelli et al. (1993) reported

no attrition. LaBarge et al. (1988) reported an attrition rate in

the experimental group of 3/11. Zanetti et al. (1995) only

provided an attrition rate for the experimental group of 7/16.

LaBarge et al.’s (1988) attrition was due to refusal to parti-

cipate. Zanetti et al. (1995) provided no reasons for attrition.

Key findings by intervention

Reality orientation

Zanetti et al. (1995) and Baldelli et al. (1993) examined the

effectiveness of reality orientation (see Table 4). Although

the studies made use of two common outcome measures –

the MMSE and Geriatric Depression Scale (GDS) (Yesavage

et al. 1983) – differences in the intervention timeframe,

together with varying attrition rates and incomplete infor-

mation about the size of study groups, precluded meta-

analysis. Instead the findings were analysed in a qualitative

manner, where appropriate, in the form of a narrative

commentary.

Baseline MMSE scores in both studies were similar. At

baseline, the mean MMSE score for the experimental groups

were 18Æ4 (Zanetti et al. 1995) and 20Æ1 (Baldelli et al. 1993);

for the control groups 20Æ0 (Zanetti et al. 1995) and 21Æ3

(Baldelli et al. 1993). Table 4 shows differences in how

the reality orientation interventions were administered. Par-

ticipants in Zanetti et al.’s (1995) experimental group

(n ¼ 16) took part in cycles of therapy, whereas those in

Baldelli et al.’s (1993) experimental group (group size not

provided) took part in a continuous period of therapy.

Neither study gave information on the activities of the

control group.

Both studies assessed cognitive ability using the MMSE,

and well-being using the GDS. Both also examined functional

performance, although the measures employed differed: digit

span (Orsini et al. 1987) in the case of Zanetti et al. (1995),

and activities of daily living (ADL) (Stewart 1980) and the

Orientation Scale for Geriatric Patients (OSGP) (Berg &

Svensson 1980) in the case of Baldelli et al. (1993). Zanetti

et al. (1995) also examined cognitive ability using the animal

naming test (Rosen 1980), and communication in terms of

verbal fluency (Novelli et al. 1986). [Note that Zanetti et al.

(1995) also examined functional performance using basic

(Katz et al. 1963) and instrumental (Lawton & Brody 1969)

ADL. However, data relating to these measures were notTable

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Table 4 Results on reality orientation (ROT)

Paper Zanetti et al. (1995) Baldelli et al. (1993)

Description of sample • 28 participants: 16 in experimental group, 12 in

control group. Gender profile not provided

• Mean age of experimental group was 73Æ4 years; for control

group, 68Æ5 years

• 23 participants, all female.

Mean age of total sample 84Æ5 years

• No details about size and composition

of the two groups

Country and

care setting(s)

Brescia, Italy. Day hospital of an Alzheimer Dementia Research and

Care Unit

Study probably took place in Italy. No

precise details given of care setting

Dementia type(s) Diagnosis of probable Alzheimer’s disease according to NINCDS-

ADRDA criteria

Alzheimer’s disease

Study groups Two: one experimental group and one control group Two: one experimental group and one

control group

Baseline mean MMSE(s) For experimental group: 18Æ4; for control group: 20Æ0 For experimental group: 20Æ1; for control

group: 21Æ3

Discipline of therapist(s) ROT provided by an occupational therapist Not stated

Attrition rate(s) Attrition rate for experimental group for completion of four ROT

cycles: 16 completed at least one cycle; 15 completed two cycles,

14 completed three cycles, and nine completed four cycles

Attrition rate was 0 in both groups

Description

of intervention(s)

and control activity

• The experimental group (n ¼ 16) divided into subgroups of three

to four participants having ROT classes 5 days per week for

1 month (this equals one ROT cycle of 20 classes)

• Each ROT class lasted 45 minutes consisting of an organized,

intensive cognitive training during which the OT gradually

presented information such as date, time, current location

• Early classes were directed towards personal, time and space

orientation; later classes focused on topics of general interest

such as famous people

• Patients prompted to give spontaneous or cued answers aided by

calendars, clocks and notes

• No details provided on activities for control group

• The experimental group participated

in a 3-month period of formal ROT.

The sessions lasted 1 hour and were

held three times a week. The control

group also met three times a week

in a different room to the study group

for the same 3-month period

• No further details provided about the

intervention, nor about the activities

of the control group

Outcome(s)

and measure(s)

• Cognitive ability – MMSE (Folstein et al. 1975)

• Communication – verbal fluency (Novelli et al. 1986)

• Cognitive ability – memory recall, animal naming (Rosen 1980)

• Functional performance – digit span (Orsini et al. 1987)

• Well-being – GDS (Yesavage et al. 1983)

• Cognitive ability – MMSE (Folstein et al.

1975)

• Well-being – GDS (Yesavage et al. 1983)

• Functional performance – ADL (Stewart

1980)

• Functional performance – OSGP (Berg &

Svensson 1980)

Data collection points • Pre- and post-test data

• Patients in experimental group evaluated at baseline, and had

treatment period averaging 8Æ2 months; post-test data collected

no later than 3 days after the last ROT session

• Patients in control group evaluated at baseline and after a mean

period of 8Æ5 months

• Pre- and post-test data (0 and 3 months)

• Follow-up data collected 3 months after

end of ROT

Key findings 1. Significant differential change in MMSE scores between

experimental groups and control group. In experimental groups,

a mild improvement (0Æ68) where control group declined (�2Æ58)

Treatment effect was 3Æ27 (95% CI: 0Æ18–6Æ36)

2. When MMSE treatment effect controlled for age, education,

baseline MMSE, disease duration, clinical dementia rating,

number of physical diseases, and time elapsing from baseline and

last assessment, adjusted treatment effect was slightly lower:

3Æ12 (95% CI: 0Æ48–6Æ84)

1. At post-test, a significant difference was

found between experimental group and

control group on MMSE (P ¼ 0Æ029); on

OSGP (P ¼ 0Æ009); on GDS (P ¼ 0Æ000)

2. At post-test, no significant difference

was found between experimental group

and control group on ADL (P ¼ 0Æ626)

J. Bates et al.


included in this review because baseline data were collected

from the primary caregiver, not through an examination of

each individual patient by a researcher.]

In Zanetti et al.’s (1995) study, a significant differential

change in cognitive ability – measured using the MMSE –

between the experimental and control groups was found.

However, no significant differential change was found

between the two groups on communication, cognitive ability

(measured by memory recall – animal naming), functional

performance and well-being.

Comparing pre- and post-test data in Baldelli et al.’s (1993)

study, a significant improvement was found in the experi-

mental group in terms of cognitive ability and functional

performance, as measured on the OSGP (see Table 4). In

addition, no significant differences were found in well-being

and functional performance (as measured on the ADL) in both

the experimental and control groups. Comparing post-test

and follow-up data, a decline in the improvement in cognitive

ability was noted in the experimental group, while there was

also a decline in cognitive ability in the control group.

Taking Zanetti et al.’s (1995) and Baldelli et al.’s (1993)

studies together, there is evidence that reality orientation is an

effective intervention in improving cognitive ability, as meas-

ured using the MMSE. Furthermore, as Baldelli et al.’s (1993)

follow-up data show, the improvement in cognitive ability,

even taking into account a decline after the end of the

intervention period, is maintained 3 months after the collection

of post-test data. Neither study demonstrated that reality

orientation is effective in improving well-being, as measured by

the GDS. Finally, no evidence was found that reality orientation

is effective in improving communication, functional perform-

ance, and cognitive ability measured in terms of memory recall.

Procedural memory stimulation

The results of Zanetti et al.’s (1997) study on procedural

memory stimulation are contained in Table 5. The study

involved 10 people with Alzheimer’s disease and 10 ‘normal

elderly controls’, who were mainly healthy spouses and

relatives of people in the experimental group. Baseline mean

MMSE scores were 19Æ8 in the experimental group and 29Æ2

Table 4 (Continued)

Paper Zanetti et al. (1995) Baldelli et al. (1993)

3. No significant differential change on the GDS. experimental group

improved (�0Æ31), while control group declined (0Æ25). The treatment

effect was – 0Æ56 (95% CI: �3Æ69–2Æ56)

4. No significant differences were found in differential change between

experimental group and control group on verbal fluency, animal

naming and digit span scores (no extractable data on this)

3. Comparing pre and post-test data,

a significant improvement was found

in the experimental group on MMSE

(P ¼ 0Æ008); and OSGP (P ¼ 0Æ004)

4. Comparing pre and post-test data,

no significant differences found in GDS

and ADL scores in both the experimental

group and the control group

5. Comparing post-test data, a significant

difference was found between the

experimental group and the control

group on MMSE-item memory (P ¼ 0Æ008);

and on MMSE- item orientation (P ¼ 0Æ037)

6. Comparing follow-up data, a significant



group on MMSE (P ¼ 0Æ032)

7. A slight decline in the improvement

in MMSE of the experimental group

was noted between post and follow-up

data (23Æ1–21Æ0). The decline in the

control group was 16Æ9–15Æ7)

8. Comparing follow-up data, a non-significant



group on OSGP (P ¼ 0Æ053)

NINCDS, National Institute of Neurological and Communicative Disorders and Stroke; ADRADA, Alzheimer’s Disease and Related Disorders

Association. MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale; ADL, activities of daily living; OSGP, Orientation Scale

for Geriatric Patients.



in the control group. Participants in the experimental group

were divided into two subgroups and trained in 15 indi-

vidualized 1-hour sessions to perform 10 ADLs (the 10

activities of the two groups were different). The 10 people in

the control group were asked to perform the 20 activities and

the time taken was recorded and used as a reference.

Functional performance and cognitive ability were

assessed using a neuropsychological battery of tests (see

Table 5). No significant improvement after stimulation was

found comparing baseline and post-test data. Zanetti et al.’s

(1997) study, therefore, did not find any evidence

in support of the effectiveness of procedural memory

stimulation, measured by cognitive ability and functional

performance.

Counselling

The results of LaBarge et al.’s (1988) study on counselling are

contained in Table 6. Nineteen participants completed the

study: eight in the experimental group and 11 in the control

group. The MMSE was not used as a measure of dementia

severity. However, all participants were defined as having mild

dementia, as measured on the Clinical Dementia Rating Scale

(Hughes et al. 1982, Berg 1984). The intervention provided to

the experimental group consisted of two counselling sessions

averaging 50 minutes. Session 1 was for test-taking, and

session 2 was for the counselling. Counselling provided an

opportunity for the client to ventilate their concerns and

receive validated information about their mental status. No

details were provided on the control group activity.

Table 5 Results on procedural memory stimulation

Paper Zanetti et al. (1997)

Description of sample • Sample size ¼ 20; mean age was 72Æ6 years

• Ten in experimental group; 10 in control group – who were usually spouse or family member of the

patients who constituted experimental group

• Mean age of experimental group was 77Æ2 years; 68Æ0 years for control group

• Gender breakdown of experimental group: nine female and one male

Country and care setting(s) Italy. Day Hospital attached to an Alzheimer’s Dementia Research and Care Unit

Study groups Two: one experimental group and one control group

Dementia type(s) Alzheimer’s disease

Baseline mean MMSE score(s) Experimental group: 19Æ8; control group: 29Æ2

Discipline of therapist(s) Two rehabilitation therapists

Attrition rate(s) None stated

Description of intervention(s)

and control group activity

• The intervention comprised 15 individualized one-hour sessions (five per week) – five patients were trained

during 3 weeks on the first group of 10 activities and the other five patients on the second group

• Patients were trained to perform 20 different basic and instrumental ADL which were them selected and

divided into two comparable groups (in terms of difficulty) each consisted of the following:

Group A: washing face; brushing teeth; preparing coffee; putting objects – knife, fork, spoon – in the correct

place; opening and closing a door; sending a postcard; reading a brief sentence; paying a cheque;

shopping with a written list; identifying currency

Group B: washing hands; dressing; opening and closing a door-lock; preparing a slice of bread with jam;

setting the table; sending a letter; copying a sentence; reading a postcard; counting currency; using the

telephone.

• Ten elderly controls were asked to perform the 20 activities and the time required to perform the tasks

was recorded and used as a reference

Outcome(s) and measure(s) Functional performance and cognitive ability, assessed using a neuropsychological battery of tests:

• Rey figure (recall) (Rey 1983)

• logical memory (Spinller & Tognini 1987)

• learning test (Spinller & Tognini 1987)

• skill learning (Perani et al. 1993)

• word-stem completion (Graf et al. 1984)

Data collection points Baseline data collection and post-test data collected within 3 days after the end of the 15 training sessions

on completion of the study

Key findings 1. Comparisons between neuropsychological tests performed before and after training showed no significant

improvement after Bonferroni correction

2. Presence of a statistical trend for the word-stem completion test in the experimental group (mean score

from 1Æ8 before training to 3Æ2 after training; P ¼ 0Æ05, t-test)

J. Bates et al.


Two outcome measures were used to assess well-being:

the Wallace Self-Concept Scale (Wallace et al. 1984)

and Spielberger State-Trait Personal Inventory (Spielberger

1985). Comparing pre- and post-test data, LaBarge et al.

(1988) concluded that the groups were essentially the same.

Effectiveness of the individual counselling sessions was not

therefore demonstrated on the outcome measures used.

Discussion

This systematic review has revealed a paucity of well-

designed studies focusing on the effectiveness of psychosocial

interventions for people with a milder dementing illness.

Only four studies were included, covering the three interven-

tions of reality orientation, procedural memory stimulation

and counselling. Effectiveness was measured on the basis of

cognitive ability, functional performance, communication

and well-being, using a variety of instruments (see Table 2).

Procedural memory stimulation was not found to have any

significant impact on functional performance and cognitive

ability (Zanetti et al. 1997). Similarly, counselling was not

found to have any significant impact on well-being (LaBarge

et al. 1988). However, little can be concluded about the

effectiveness of procedural memory stimulation and counsel-

ling on the findings of these two studies alone, because the

sample sizes were small, and no consideration was given to

statistical power (see Table 4). More research is therefore

needed on both these interventions, employing sample sizes

Table 6 Results on counselling

Paper LaBarge et al. (1988)

Description of sample • Sample size ¼ 22, comprising 12 male and 10 female. Average age was 74Æ0 years.

• Eleven people randomly assigned to the experimental and control groups

• Number of subjects completing study – eight in experimental group (four male and four female); and

11 in the control group (six male and five female). Mean ages of the two groups not given

Number of study groups Two: one experimental group and one control group

Country and setting(s) United States of America. No information on the specific care setting.

Dementia type(s) Alzheimer’s

Baseline mean MMSE(s) MMSE not used. Mild SDAT was diagnosed using the Clinical Dementia Rating Scale (Hughes et al. 1982,

Berg 1984)

Discipline of therapists First and third authors reported as ‘doctoral-level counselling students’, who also provided the therapy

Attrition rate(s) Two males refused counselling from the original 22 participants. Also, one female dropped out

of the study. Attrition of three of 22, all from the experimental group

Outcome and measure(s) • Well-being: (for client to be able to vent concerns and receive validated feedback re their mental status)

Wallace Self-Concept Scale (Wallace et al. 1984)

• Spielberger State-Trait Personality Inventory – examining anger, anxiety and curiosity (Speilberger 1985)

Description of

intervention(s)

and control

group activity

• Within the experimental group, each client counselled individually for two sessions averaging 50 minutes.

Session 1 was for test-taking session. Session 2 was a counselling session. The counselling session was

planned to provide an opportunity for the client to ventilate concerns and receive validated information

about his/her mental status. The session was structured around the following stages: develop rapport;

gather information about the patient’s feelings as to memory change; explore alternatives and ways

to deal with losses for the short term; confront incongruities; and receive information. The session was

designed to help the patient to deal with short-term memory loss, maintain as much self-determination

as possible; and to alleviate stress, frustration and anxiety

• No details given on control group activity

Data collection points • Baseline and post-test data. No follow-up

• Time frames from pre-test to post-test ranged from 21 to 65 days (mean 43 days)

Key findings 1. Comparing pre- and post-tests on the two measures, ‘the groups were essentially the same at pre- and

post-test’. This was ascertained by using a linear regression to predict post-test scores using pre-test scores,

in order to remove the effects of an explained relationship between the two, to isolate the counselling

effects. Residual scores obtained by this procedure analysed in a multivariate analysis of variance.

Detailed statistics not extractable

2. Qualitatively, authors learned that patients seek to compensate for their dementia. Patients noted to ask

for reading material regarding their condition; something to help with their losses; a talking session to

help approach memory failure cognitively

SDAT, Senile Dementia of the Alzheimer’s Type



of sufficient statistical power and, in the case of counselling,

over a longer intervention timeframe.

Some evidence was found in the two included studies on

reality orientation (Baldelli et al. 1993, Zanetti et al. 1995)

that this is effective in improving cognitive ability, as

measured by the MMSE. Evidence was also found that

improvements in cognitive ability were maintained, albeit

taking into account a small decline, when post-test and

follow-up data were compared. This finding must be treated

with caution due to the small sample sizes involved. No

evidence was found in the two included studies that reality

orientation is effective in improving well-being and func-

tional performance.

All included studies made use of the prospective treatment

study design, with experimental and control groups. Although

this design has rigour in assessing the effectiveness of psycho-

social interventions, the methodological quality of included

studies was uneven, raising important issues for future

research in this field. First, sample sizes tended to be small,

with a reliance on convenience sampling, so that the likelihood

of all four included studies being sufficiently powered is open

to question. Secondly, random allocation to study groups was

not mentioned in three of the included studies in which it was

appropriate to do so. In the study where randomization

occurred (LaBarge et al. 1988), the method by which it was

achieved was not described. Thirdly, blinding to the measure-

ment of outcomes was only described in two of the studies

(Zanetti et al. 1995, 1997). Finally, only one study included

the collection of follow-up data, to examine the longer-term

impact of the intervention (Baldelli et al. 1993).

No comparative studies were included in the review. We

cannot say whether, for example, reality orientation is more

effective than procedural memory stimulation for people with

a milder dementia. Furthermore, no studies were included

which examined the effectiveness of psychosocial and phar-

macological interventions in combination. Comparative and

combined studies are therefore needed to examine these issues.

Implications for future empirical research

The dearth of literature on the effectiveness of psychosocial

interventions for people with a milder dementia, together

with the need for combined and comparative studies, raises

important research and resource issues. However, as Mar-

shall and Hutchinson (2001, p. 493) rightly point out, ‘Doing

research with individuals with [dementia] is extremely

difficult. We commend investigators who have initiated

research with this population’. This difficulty is compounded

by the time and cost of the enterprise (Clare 1999). It is

perhaps hardly surprising that the studies included in this

review relied on small sample sizes, single-site settings and

convenience sampling.

Over-reliance on convenience sampling in dementia re-

search, as highlighted by Marshall and Hutchinson (2000) and

also demonstrated in this review, must be addressed for

progress to be made in establishing a stronger evidence base for

the clinical effectiveness of psychosocial interventions. Con-

venience samples are likely to include clients at different stages

of dementia, and we had to exclude many studies for that

reason. We would argue that the use of such heterogeneous

client groups raises doubts about the validity and reliability of

outcome measurements. Moreover, heterogeneity impacts on

the effectiveness of the intervention, and thus on the quality of

care received by clients. This issue was discussed by Goldw-

asser et al. (1987, p. 220) in their study of reminiscence

therapy: ‘from a clinical standpoint the heterogeneity of

patients within groups posed something of a problem during

the actual sessions…the combination of mildly confused but

depressed clients combined with significantly impaired resi-

dents resulted in social and management difficulties’.

It is important, therefore, that future researchers ensure,

through screening, that clients at each research setting are

appropriate for the study in terms of prespecified inclusion/

exclusion criteria so that, as far as possible, study groups are

homogeneous in terms of their stage (and type) of dementia, and

the extent of co-morbidities such as depression. To tackle some

of the practical issues of recruiting sufficient people with

dementia for future work in this area, we would recommend

funding multi-centre randomized controlled trials. Such a design

should ensure that research is undertaken with sample sizes of

sufficient statistical power, and with client groups homogeneous

in terms of the stage of their dementing illness. Multi-centre trials

are needed to explore more fully the effectiveness of the included

interventions in this review, and also other interventions that are

potentially beneficial for people with a milder dementia, such as

reminiscence therapy, exercise, arts therapies, and combination

therapies such as exercise and memory training.

Implications for nursing practice

Because of the small number of studies included in this

review, it is difficult to make any definitive statement on

implications for nursing practice. There was no evidence that

counselling or procedural memory stimulation are effective.

However, there is evidence that reality orientation holds

promise as a therapy to improve cognitive ability in this client

group. Due to the small sample sizes of included studies,

however, further research is needed before counselling,

procedural memory stimulation and reality orientation can

be recommended for clients with a milder dementia.

J. Bates et al.


In applying rigour in our methodological approach to this

systematic review, it has been necessary to discard several

potentially valuable pieces of research – usually on the basis

of mixed client groups. Nearly all of these excluded studies

were conducted in existing clinical facilities such as day

hospitals, day centres and residential homes, where it is

fairly common to admit clients routinely and immediately

after referral, in order to satisfy the need to be seen to be

managing a fully utilized nursing facility. This system of

admission (however necessary) militates against a more

individualized and targeted approach to psychosocial inter-

ventions, where dementia type, dementia severity and indeed

age might be taken into account prior to admission, and

where clients are allocated to groups/days/facilities accord-

ing to their individual needs. Within the spirit of patient-

centred approaches to dementia care (Kitwood 1997),

psychosocial interventions provided by nursing staff to

people with dementia should be as individually targeted as

possible, and thus appropriate to the stage of dementia

being experienced.

From the 208 potentially includable papers that were

acquired in this review, it became clear that a pattern of

psychosocial interventions was beginning to emerge, suggest-

ing that clinicians and researchers were discriminating in

their use and applying them to people at appropriate, more

specific stages of dementia. It was found, for example, that

memory re-training using errorless learning techniques and

computer activities were targeted at people with a milder

dementia, whereas multi-sensory therapies involving, for

example, massage and music, were largely targeted at people

with a more severe stage of dementia. We are currently

collating this evidence to provide an evidence-based model of

psychosocial interventions currently in use in dementia care.

This model should prove useful in providing guidance to

nursing staff on the most appropriate psychosocial interven-

tions for clients at particular stages of dementia.

Limitations and recommendations for further systematic

reviews

The review has a number of limitations. First, due to

budgetary constraints, only papers published in English

were included. Secondly, the review’s focus was on the

effectiveness of psychosocial interventions rather than the

effectiveness of interventions that promote psychosocial

outcomes. Therefore, studies that examined the effectiveness

of memory wallets and other prosthetic and technology-

based memory aids were excluded (e.g. Bourgeois 1990,

Bourgeois & Mason 1996, Hofmann et al. 1996, Panza

et al. 1996, Bourgeois et al. 2001). Although these

interventions promote psychosocial outcomes such as

improved cognitive ability and communication, they were

excluded from the review because the interventions in

themselves were not considered psychosocial, using our

adopted definition. A systematic review of interventions to

promote psychosocial outcomes for people with a milder

dementia would therefore be useful. Furthermore, there is

scope for a systematic review focusing on the effectiveness

of psychosocial interventions for people with moderate or

severe dementia.

Conclusion

Early intervention for people with dementia is being given

UK Department of Health priority (Department of Health

2001). To reflect the implied distinction between those in

the early and latter stages of the illness, we would argue

that research taking place in clinical practice needs to be

specific and particular with regard to dementia severity in

client groups. Therefore, there is a need for targeted

interventions (psychosocial and/or pharmacological) to be

provided by nurses and other practitioners for clients at an

appropriate stage of their illness. Future research could also

focus on the effectiveness of joint pharmacological and

psychosocial interventions designed to maximize the oppor-

What is already known about this topic

• Psychosocial interventions form an important part of

modern non-pharmacological treatment for people with

dementia.

• A number of systematic reviews have been undertaken

to examine the effectiveness of individual psychosocial

interventions, such as music therapy, reminiscence

therapy, validation therapy and reality orientation.

What this paper adds

• To date, little account has been taken in published

systematic reviews of the appropriateness of psycho-

social interventions for people in different stages of the

illness.

• An evaluation of the effectiveness of psychosocial

interventions for people in the milder stages of demen-

tia.

• Little high-quality evidence was found, although there is

some evidence to suggest that reality orientation holds

promise as an effective psychosocial intervention for

people in the milder stages of dementia.



tunities for people with dementia to lead as normal a life for

as long as possible.

Acknowledgements

The authors would like to thank advisory group members Dr

Jane Barton, Dr Robert Dixon, Sue Elliott, Dr Jerry Seymour

and Dr Tony Ryan. They would also like to thank Professor

Glenys Parry and Dr Elaine Plesner for their assistance in

developing the research, Dr Daniel Hind for his advice on meta-

analysis and Naomi Brewer for her detailed proof reading.

The project was funded by a research grant from the

Sheffield Health and Social Research Consortium.

Author contributions

All listed authors have contributed directly to this study and

this paper. JBates and JBoote contributed to the study

conception and design, and obtained the funding. They were

also responsible for the data collection, data analysis and

drafting of the manuscript. JBoote and CB carried out critical

revisions of the manuscript and JBoote provided statistical

expertise and supervision. JBates provided administrative and

technical support, and CB carried out literature searches.

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Appendix 1. Sources searched

Major bibliographical databases searched

1 AMED

2 British Nursing Index

3 CINAHL

4 Cochrane Controlled Trials Register (CCTR)

5 Cochrane Database of Systematic Reviews (CDSR)

6 Embase

7 Health Management Information Consortium (HMIC)

8 Medline

9 NHS Database of Abstracts of Reviews and Dissemin-

ation (DARE)

10 NHS Economic Evaluations Database (EED)

11 NHS Health Technology Assessment (HTA) database

12 PreMedline

13 PsycINFO

14 Science Citation Index

15 Social Science Citation Index

Additional sources searched

1 Bandolier

2 Development and Evaluation Committee (DEC) reports

3 Google

4 National Guideline Clearinghouse

5 National Research Register

6 National Co-ordinating Centre for Health Technology

Assessment (NCCHTA)

7 The library catalogue of the School of Health and Related

Research, University of Sheffield

8 Scottish Intercollegiate Guidelines Network (SIGN)

9 Trent Working Group on Acute Purchasing (TWGAP)

reports

Appendix 2.

Sample search strategy used in Ovid Medline

(1966–April 2002)

1 exp dementia/

2 dement$.ti

3 alzheimer$.ti

4 exp memory disorders/

5 or/1–4

6 (non-pharmacolog$ or non-pharmacolog$ or non-phar-

macolog$).tw

7 exp psychotherapy/

8 (cognitive adj2 therap$).tw

9 ((psychosocial$ or psychosocial$ or psycholog$ or so-

cial$) adj2 (intervention$ or therap$)).tw



10 exp counselling/

11 ((art or draw$ or music or humour or writing or dance or

dancing or paint or painting or visual or sing$ or song

or instrument$ or play or drama or relax$) adj2

therap$)).tw

12 writing/

13 humour$.tw

14 laughter.tw

15 fun.tw

16 person centred.tw

17 person centered.tw

18 personhood.tw

19 validation therap$).tw

20 reminiscence therap$.tw

21 life memor$.tw

22 (life story or life stories).tw

23 exp social environment/

24 memory stimulation.tw

25 reality orientation.tw

26 reality therapy/

27 exp *memory disorders/rh

28 reorientation.tw

29 exp ‘rehabilitation of speech and language disorders’/

30 ((language or speech) adj2 (therap$ or rehab$)).tw

31 exp life style/

32 exp exertion/

33 physical fitness/

34 exercise$.ti

35 exp sports/

36 tai chi.tw

37 exp exercise therapy/

38 aerobic.tw

39 swim$.tw

40 exp diet therapy/

41 exp alternative medicine/

42 gingko biloba/

43 drugs, Chinese herbal/

44 plants, medicinal/

45 or/6–44

46 5 and 45

J. Bates et al.


psychosocial interventions for people with a milder dementing illness: a systematic review

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