Non-pharmacologic interventions for dementia patients with aggression symptoms

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For patients with dementia who have symptoms of aggression and agitation, interventions such as outdoor activities, massage and touch therapy may be more effective treatments than medication in some cases, suggests a study. The systematic review and meta-analysis, led by St Michael’s Hospital of Unity Health Toronto and the University of Calgary, suggest outdoor activities were more clinically effective than anti-psychotic medication for treating physical aggression in patients with dementia. For patients with physical agitation, massage and touch therapy were more efficacious than usual care or caregiver support.

“Dementia affects 50m people worldwide and as many as three quarters of those living with the disease have reported neuropsychiatric symptoms including aggression, agitation and anxiety,” said Dr Jennifer Watt, a researcher at the Li Ka Shing Knowledge Institute of St Michael’s Hospital. “Unfortunately, our understanding of the comparative efficacy of medication versus non-medicine interventions for treating psychiatric symptoms has been limited due to a lack of head-to-head randomised controlled trials of the two routes.”

To address this gap, researchers led by Watt, who is also a geriatrician; Dr Sharon Straus, director of the Knowledge Translation Programme at St Michael’s; and Dr Zahra Goodarzi, a geriatrician and researcher at the University of Calgary, worked with 12 dementia care partners to select study outcomes based on commonly reported neuropsychiatric symptoms of the disease. They identified reports of improvement in aggression and agitation to be the main two outcomes to focus on in the analysis and review.

The study’s findings are based on an analysis of 163 randomised controlled trials involving 23,143 people with dementia and the study of pharmacologic or non-pharmacologic interventions to treat aggression and agitation.

Though the study allows for the comparison of the two types of interventions, the researchers point out that neuropsychiatric symptoms of dementia do not have a one-size-fits-all solution.

“Treatment should be tailored to the patient and their specific experience,” said Straus, who is also a geriatrician at St Michael’s. “This study, however, does shed light on the opportunity to consider prioritising different types of interventions for aggression and agitation when appropriate.”

Further research, Watt said, will aim to understand the influence of individual patient characteristics on their response to interventions. The researchers also note the need for an analysis of the differences in cost between pharmacologic and non-pharmacologic interventions to treat aggression and agitation in patients with dementia.

“This study shows us that multidisciplinary care is efficacious, and that is consistent with a person-centred approach to care,” Watt said. “It points to evidence of the benefit of supporting multidisciplinary teams providing care to patients in the community and nursing home settings.”

Abstract
Background: Both pharmacologic and nonpharmacologic interventions are used to treat neuropsychiatric symptoms in persons with dementia.
Purpose: To summarize the comparative efficacy of pharmacologic and nonpharmacologic interventions for treating aggression and agitation in adults with dementia.
Data Sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO between inception and 28 May 2019 without language restrictions; gray literature; and reference lists scanned from selected studies and systematic reviews.
Study Selection:
Randomized controlled trials comparing interventions for treating aggression and agitation in adults with dementia.
Data Extraction: Pairs of reviewers independently screened studies, abstracted data, and appraised risk of bias.
Data Synthesis: After screening of 19 684 citations, 163 studies (23 143 patients) were included in network meta-analyses. Analysis of interventions targeting aggression and agitation (148 studies [21 686 patients]) showed that multidisciplinary care (standardized mean difference [SMD], −0.5 [95% credible interval {CrI}, −0.99 to −0.01]), massage and touch therapy (SMD, −0.75 [CrI, −1.12 to −0.38]), and music combined with massage and touch therapy (SMD, −0.91 [CrI, −1.75 to −0.07]) were clinically more efficacious than usual care. Recreation therapy (SMD, −0.29 [CrI, −0.57 to −0.01]) was statistically but not clinically more efficacious than usual care.
Limitations: Forty-six percent of studies were at high risk of bias because of missing outcome data. Harms and costs of therapies were not evaluated.
Conclusion: Nonpharmacologic interventions seemed to be more efficacious than pharmacologic interventions for reducing aggression and agitation in adults with dementia.

Authors
Jennifer A Watt; Zahra Goodarzi; Areti Angeliki Veroniki; Vera Nincic; Paul A Khan; Marco Ghassemi; Yuan Thompson; Andrea C Tricco; Sharon E Straus

St Michael’s Hospital material Annals of Internal Medicine abstract

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