Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-059aPsychological and Psychosocial InterventionsEdgar MillerCentre for Applied Psychology, University of Leicester, UKPsychological interventions in dementia offer attempts to amelioratethe consequences of the disorder. They do not affect theunderlying pathological process but are directed at helping thoseafflicted to function better and more independently. Interventionsof this kind are based on the implicit assumption that those withdementia remain sensitive to environmental influences, eventhough the extent to which this is the case may be reduced.There is now good evidence that this assumption is justified 1,2 .GENERAL METHODSPsychosocial interventions in dementia have been dominated by anumber of approaches, which are designed to be generallyapplicable to all sufferers. These carry with them, whetherexplicitly or implicitly, the assumption that attention to a keyimpairment or principle is the key to effective intervention.The assumption that an important feature of those withdementia is that they lose their orientation to time, place andperson, lies behind reality orientation (RO), which is the earliestof these general methods 3 . There are two facets to RO. Firstly,regular group sessions, known as ‘‘classroom’’ or ‘‘group RO’’,involve sessions in which members may be led to recall the dateand time of year, where they are, and so on. Secondly, ‘‘24-hourRO’’ may operate continuously and involves all who come intocontact with sufferers, stressing information relating to orientation.An example of this is the nurse saying, ‘‘It is now 12 o’clockand time to take your tablets, Mrs Smith’’. This emphasizesinformation relating to time and person and links the time to theactivity to be undertaken.Evaluative studies have largely concentrated on group ratherthan 24 hour RO. In a review of these 4 , it was concluded thatsessions did lead to increases in verbal orientation (e.g. groupmembers are more likely to be able to say what day it is). When itcomes to changes in a wider range of cognitive functions or inbehaviour, the evidence is very much less convincing.Another general approach is that of reminiscence. This wasoriginally proposed for normally functioning old people and islinked to the assumption that reminiscence and life review is amajor task of old age. As used with those who suffer fromdementia, it also builds on an area of relative strength, that ofmemory for the distant past. Group sessions are organized, withparticipants discussing how things used to be, usually with specialmaterials such as photographs of the local city centre as it used tobe 40–50 years ago. Reminiscence about how things were can beused as a basis for turning the discussion to how things are now.Like RO, reminiscence has been popular, but relevant researchhas not offered strong support. The evidence that old people areespecially prone to reminisce or that it necessarily leads tobeneficial effects, such as increases in well-being or mood, hasproved far from overwhelming 5 . Attempts to formally evaluateeffectiveness in those with dementia have produced both negativefindings 6 as well as some indications of modest benefit 7 .A more recent development of relevance to this section is whathas become known as ‘‘dementia care mapping’’ (DCM), which isbased on the writings of Tom Kitwood 8,9 . Kitwood stressed the‘‘personhood’’ of people with dementia, and in his view the centralaspect of personhood is found in social relationships with others.Good care is that which enhances personhood and well-being interms of such things as enhancing self-esteem, enabling individualsto influence their own personal lives, promoting socialconfidence in terms of being at ease with others, and a sense ofhope.DCM is built more on a set of values than psychologicalprinciples, albeit values that almost no-one who is concerned forthe welfare of these people would wish to dissent from, at least ingeneral terms. What is lacking in this general approach is anydetailed analysis of how these might best be turned into caringpractices for elderly people with dementia, other than by feedbackfrom an evaluative process, or ‘‘dementia care mapping’’ as morenarrowly defined 10 , to assess quality of care. This is based, firstly,on coding activities or inactivities according to whether they areexpressions of ‘‘well-being’’ or ‘‘ill-being’’. Secondly, there isrecording of episodes in which the person is demeaned ordiminished. The obvious problems are those of reliably definingwhat is ‘‘well-being’’, ‘‘demeaning’’, etc., and no data as to thereliability of the method appear to be available.This is just a selection of the general approaches or methodsthat are available and others are described elsewhere 1,2 . Most ofthese suffer from the limitation that, explicitly or implicitly, theysee the problem of dementia as a single issue (e.g. loss oforientation in RO) or, as in the case of DCM, offer a set of verygeneral values and principles. The best evidence as to effectivenessis still for RO, although even the positive impact of that is limitedin extent. However, the search for better methods of care is notnecessarily futile, since there is evidence that different forms ofintervention, such as altering the layout of the furniture to makeinteraction easier, or enhanced activity programmes, can produceimprovement 11,12 .SPECIFIC METHODSAs already indicated, approaches like those described in theprevious section all assume a particular key factor, whether it belack of orientation or the minimizing of personhood, offers thePrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd