A theme is emerging.
Put briefly, “There is not enough high quality data.” By ‘high quality’ I mean large scale population studies with randomised testing and control groups using consistent methodologies which enable the researchers to pick apart the contributing factors to any effects measured.
There are lots of small scale studies: the papers by Holm et al. (2005) and Lepp et al. (2003) are good examples of the type. (They report different aspects of the same research project.) The work is done carefully and is well documented but the numbers are necessarily small. The results are encouraging though.
Lepp’s group looked at the impact of separate drama and storytelling workshops on the behaviours of small groups of people with dementia. The group observed improvements in behaviour, motivation and activity over the course of the intervention and beyond. One really interesting observation was that the participants were capable of associative conversation and this form of conversation improved over the course of the project. The participants became increasingly able to recognise one-another and the workshop(s) leaders. The positive benefits carried on beyond the interventions themselves with participants demonstrating an increased willingness to engage with other people and their surroundings.
One of the interesting elements of the storytelling workshop is that the progression of stories told was carefully constructed, following Erikson’s life-phases framework, with the first story beginning in an early stage of life moving, over the course of the 6 workshops to dealing with issues around the later stage of life that the participants were in. The participants responded to these themes and their conversation moved via association to linked themes in their own lives and wider existential questions. This progression perhaps addresses some of the reservations expressed by Woods (2005a) that reminiscence leaves a discontinuity between the memories evoked and the current, lived situation of the person remembering.
Storytelling and drama, then, might be added to the list of potential, non-pharmacological approaches identified by Douglas et al. (2004). They list…
Behavioural therapy; Reality orientation; Validation therapy; Reminiscence therapy
Art therapy; Music therapy; Activity therapy; Complementary therapy; Aromatherapy; Bright-light therapy; Multisensory approaches
Cognitive–behavioural therapy; Interpersonal therapy
Douglas and co-authors (2004) argue that pharmacological approaches are not always effective and that these approaches should be considered, though Junaid & Hegde (2007) identify an on-going resistance to these types of approaches within the medical community. (Junaid & Hegde would add ‘supportive psychotherapy’ to that final group in the list.)
Douglas et al. identify common features amongst the approaches that they review. These are: “One striking thing is the move towards more person-centred forms of care. Within this approach, greater attempts are made to understand the individual’s experience of dementia and to employ strategies to improve the person’s quality of life. A further shared feature is the systemic perspective, that is, the need to work with systems (families, professional carers, organisations, etc.). Indeed, care staff and families are usually integral to treatment strategies. It is evident, therefore, that training of carers (both professional and family) is an important part of most treatment programmes. In fact, one study study (Bird et al, 2002) suggested that the most common interventions for psychological and behavioural symptoms of dementia were not necessarily specific therapies but working with carers or nursing home staff to change the attitudes and behaviour of those in their care.”
The review by Douglas carries an “Invited Commentary” by Woods. He helpfully observes that the aims of these therapeutic approaches are not always clear or, if they are clear, they vary from therapy to therapy. So… “Reality orientation, for example, has had a clear focus on cognition, particularly orientation. In a recent trial, the changes in cognitive function were of the same order of magnitude as those reported in trials of acetylcholinesterase inhibitors. In its new form, it is associated with improvements in quality of life, but there is no suggestion that it would, or should, affect BPSD [behavioural and psychological symptoms of dementia]. Reminiscence work has had a variety of aims, plausibly spanning both cognition (autobiographical memory) and mood. Validation therapy, with its emphasis on the emotional content of communication, similarly should have its main impact on affect. The ‘alternative’ therapies also have a range of potential aims, although the putative impact of aromatherapy and music therapy on arousal levels is of particular interest, if this is seen as a possible factor in behaviours described as agitated.”
Douglas, S., James, I. & Ballard, C. (2004) ‘Non-pharmacological interventions in dementia’, Advances in Psychiatric Treatment, vol. 10, 171–179
Holm, A.-K., Lepp, M. & Ringsberg, K.C. (2005) ‘Dementia: involving patients in storytelling – a caring intervention. A pilot study’, Journal of Clinical Nursing, 14, 256–263
Junaid, O. & Hegde, S. (2007) ‘Supportive psychotherapy in dementia’, Advances in Psychiatric Treatment, vol. 13, 17–23
Lepp , M., Ringsberg, K.C., Holm, A.-K. & Sellersjo, G. (2003) ‘Dementia – involving patients and their caregivers in a drama programme: the caregivers’ experiences’, Journal of Clinical Nursing, 12: 873–881
Mitty, E. (2009) ‘Storytelling’, Geriatric Nursing, Volume 31, Number 1, 58-62