Dealing with the agitation, anxiety and aggression that often come with dementia is one of the most challenging aspects of caring for someone with this brain disorder. But new research suggests that massage and other non-drug treatments may be more effective than medications.
Even just taking people with dementia outdoors can help, said study author Dr Jennifer Watt, a geriatrician and clinical scientist at the Li Ka Shing Knowledge Institute at St. Michael's Hospital-Unity Health in Toronto.
"The bottom line from our study is that non-medication based therapy and multidimensional care seem to be better than medications for treating the symptoms of aggression and agitation in persons with dementia," she said.
Dementia, a progressive loss of thinking and memory skills, affects 50 million people worldwide. Up to three-quarters have behavioural and psychological symptoms. People with such symptoms often need institutionalised care sooner.
A variety of dementias
Health care professionals rely on several medications to lessen symptoms of agitation and aggression, but these medications carry significant risks. One, ironically, is worsening memory and thinking, the researchers said.
Some medications – such as anti-psychotics – may do little to control symptoms, according to the American Board of Internal Medicine Foundation. Plus, they carry the US Food and Drug Administration's most serious warning, because they increase the risk of stroke and death in people with dementia.
Given the challenges of using medications, researchers wanted to know more about alternatives, Watt said.
They included 163 studies in their analysis, with a total of more than 23 000 people. Studies included drug and non-drug interventions.
In most of the studies, the patients' average age was 75 or older. There were a variety of dementias, such as Alzheimer's disease and vascular dementia, in stages from mild to severe.
Medications studied included antidepressants, antipsychotics, dementia-specific medications, cannabinoids and a combination medication, dextromethorphan-quinidine (Nuedexta), to treat uncontrollable laughing or crying.
Outdoor activities most effective
Non-drug interventions included changes in environment, outdoor activities, recreational therapy, exercise, massage, music therapy and cognitive stimulation as well as caregiver education and support.
Researchers found that outdoor activities were the most effective for reducing agitation and aggression. Outdoor activities, massage and touch therapy ranked highest for treating verbal aggression. Exercise and modifying daily activities seemed best for dealing physical aggression, the study reported.
Nuedexta and medications from cannabis were more effective than a placebo in reducing agitation and aggression. But Watt said these drugs aren't prescribed much, and there may be side effects.
"It's important to prioritise the use of non-medication based treatment as much as possible," she said.
Watt acknowledged that it's not possible to implement all or even some of these non-drug treatments.
"Caregiving is hard," Watt said. "People are doing the best they can with the time and resources they have. We need to raise awareness and advocate for more financial resources to support these types of interventions."
Medication not always best option
That said, she noted that some interventions can be simple. A music player with headphones can soothe, and just getting outdoors can help. If someone is in a nursing home, Watt suggested decorating their room with photos and other objects that bring back pleasant memories.
Keith Fargo, director of scientific programmes and outreach for the Alzheimer's Association, reviewed the analysis and called it an informative look at an important problem.
"Aggression, agitation and other non-cognitive symptoms of dementia are often overlooked, but the reality is, for most people with dementia, the non-cognitive symptoms can be more problematic," he said. "These behaviours are very disruptive to daily life and family harmony, and the need for effective treatments is great."
As this study found, Fargo noted, medications are not always the best option.
"Some of this has to do with paying attention to people," he said. "When people have moderate to severe dementia, they have difficulty communicating. They may be feeling discomfort and can't communicate that they don't like a certain chair or that they're too hot. Then they may act out. So, sometimes, it's a matter of small things in the environment that can be changed."
Fargo agreed with Watt that "person-centred care" can be demanding.
"Caregiver burden is a real problem, and some people may be overwhelmed. But you don't have to do it all. A first-line approach should be trying to understand what may be happening in that person's world," he said.
The study was published in the Annals of Internal Medicine.
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