Evidence‐based Synthesis

Program (ESP)

A Systematic Evidence Review of 

ph lil armacological I t ti n erventions 

Behavioral Sy p m toms of Deme

Portland VA Medical Center

June 23, 2011
Evidence‐based Synthesis

Program (ESP)

Acknowledgements

Co‐Authors

o Maya O’Neil, Ph.D.

o Michele Freeman, M.P.H.

Reviewers

o Susan Cooleyo Bradley Karli

o Vivian Christensen, Ph.D.

o Robin Telerant, M.D.

o Ashlee Addleman, M.P.H.

o Gregory Hinro Dorothy Moo

o Ashlee Addleman, M.P.H. o Robert Ruff, o Devan Kansagara, M.D.

o Robert Ruff, o Beverly Prief
Evidence‐based Synthesis

Program (ESP)

Acknowledgements

Presenters & Discussants

Maya O’Neil, Ph.D.

Gregory Hinrichsen Ph D Gregory Hinrichsen, Ph.D.

Susan Cooley, Ph.D.

Bradley Karlin Ph D Bradley Karlin, Ph.D.
Evidence‐based Synthesis

Program (ESP)

Disclosure

This report is based on research research conducted conducted by the Evidence Evidence‐based 

Program (ESP) Center located at the Portland VA Medical Center fu

Department of Veterans Affairs, Veterans Health Administration, Of

Research Research and Development Development, Health Services Services Research Research and Develop

Develop

findings and conclusions in this document are those of the author(s

responsible for its contents; the findings and conclusions do not ne

represent represent the views of the Department Department of Veterans Veterans Affairs Affairs or the U

government. Therefore, no statement in this article should be cons

official position of the Department of Veterans Affairs. No investiga

affiliations affiliations or financial financial in ol ement volvement (e g. ., emplo ment y , cons ltanci

ultanci

stock ownership or options, expert testimony, grants or patents rec

pending, or royalties) that conflict with material presented in the re
Evidence‐based Synthesis

Program (ESP)

VA Evidence‐based Synthesis (ESP)

Program Overview

• Sponsored by VA Office of R&D and HSR&D.• Established Established to provide provide timely and accurate accurate syntheses/reviews syntheses/reviews 

topics identified by VA clinicians, managers and policy‐maker

work to improve the health and healthcare of Veterans.

• Builds on staff and expertise already in place at the Evidence‐

Practice Centers (EPC) designated by AHRQ. Four of these EPESP Centers:

o Durham VA Medical Center; VA Greater Los Angeles Healt

System; Portland VA Medical Center; and Minneapolis VA 

Center.
Evidence‐based Synthesis

Program (ESP)

• Provides evidence syntheses on important clinical practice to

to Veterans, and these reports help:

o d l eve op cli i l n ca poli i c es if d n ormed by evidence,

o the implementation of effective services to improve 

outcomes and to support VA clinical practice guidelin

performance measures, and

o guide the direction for future research to address gap

knowledge.

• Broad topic nomination process – e.g. VACO, VISNs, field – fa

ESP Coordinating Center (Portland) through online process:

http://www.hsrd.research.va.gov/publications/esp/TopicNomin
Evidence‐based Synthesis

Program (ESP)

• Steering Committee representing research and operations (PC

and VISN) provides oversight and guides program direction.

• Technical Advisory Panel (TAP)

o Recruited for each topic to provide content expertise

o Guides topic develop ; ment refines the key questions

o Reviews data/draft report.

• External Peer Reviewers & Policy Partners

o Reviews Reviews and comments comments on draft report

• Final reports posted on VA HSR&D website and disseminated 

through the VA.

http://www.hsrd.research.va.gov/publications/esp/reports
Evidence‐based Synthesis

Program (ESP)

Current Report

A Systematic Evidence Review of Non‐pharm

I t ti n erventions for Bh i l e avioral S t ymp oms of D 

(March 2011)

Full‐length report available available on ESP website: website:

http://www.hsrd.research.va.gov/publications/esp/reports
Evidence‐based Synthesis

Program (ESP)

Overview of Today’s Presentation

• Background: Why is this topic of interest

• Scope of the review

• Findings

• Cognitive/Emotion‐oriented Interventions

• Sensory Stimulation Interventions

• Behavior Management Techniques

• Other Psychosocial Interventions

• Various Various Interventions Interventions Targeting Targeting a Specific Specific Behavioral Behavioral Sym

Sym

• Limitations• Future Research
Evidence‐based Synthesis

Program (ESP)

Dementia: DSM‐IV‐TR Definition

• Multiple cognitive deficits that include memory impairment and at 

following cognitive disturbances: aphasia, apraxia, agnosia, or a dist

executive functioning

• Significant impairment in occupational or social functioning• Decline from previous higher level of functioning• Li t d s e according to presumed eti l o ogy: D ti emen a of the Al h i ’ Alzheimer’

Dementia, Dementia Due to Other General Medical Conditions (e.g

trauma, Parkinson’s Disease, Huntington’s Disease), Substance‐Indu

Dementia Dementia (drug abuse, medication medication, toxin exposure) exposure), Dementia Dementia Due 

Etiologies, or Dementia Not Otherwise Specified
Evidence‐based Synthesis

Program (ESP)

Questions for the Audience

( d Respond in your “ ” Q&A tab, upper l f e t corner)

• How do you and your colleagues colleagues treat deme

deme

• What do you think are the most effective tr

and wh ?y

• What treatment(s) would you want for your

loved one who was diagnosed with dement
Evidence‐based Synthesis

Program (ESP)

Background

• In 2004, the Office of the Assistant Deputy Under Secretary for Hea

and Planning estimated that the total number of Veterans with dem

as high as 563,758 in FY 2010.

• The VHA Office of Geriatrics and Extended Care (OGEC) convened a

interdisciplinary Dementia Steering Committee (DSC) in December 

goal of making recommendations recommendations on comprehensive, comprehensive, coordinated coordinated c

with dementia.

• The DSC requested VA HSR&D’s Evidence‐based Synthesis Program 

evidence evidence on selected selected topics, in order to assist with DSC planning planning eff

eff
Evidence‐based Synthesis

Program (ESP)

Key Questions

• Key Question 1: How do non‐pharmacological treatments of b

symptoms compare in effectiveness with each other, with phapp , roaches, and with no treatment?

• Key Question 2: How do non‐pharmacological treatments of b

symptoms symptoms compare compare in safety with each other, with pharmaco

pharmaco

approaches, and with no treatment?

• Key Question Question 3: How do non‐pharmacological pharmacological treatments treatments of b

b

symptoms compare in cost with each other, with pharmacoloapproaches, and with no treatment?
Evidence‐based Synthesis

Program (ESP)

Methods

• Searched MEDLINE, Cochrane Database of Systematic Review

Cochrane Database of Reviews of Effects through 2009 for sys

reviews related to dementia

• Additional articles obtained from reference lists• We conducted a search of primary studies of animal‐assisted 

because because there were no existing existing systematic systematic reviews reviews on this top

• Additional primary studies were suggested for inclusion by re

on recency and relevance to the field
Evidence‐based Synthesis

Program (ESP)

Results

• 21 good quality systematic reviews each examined a single n

pharmacological intervention; seven good quality systematic 

reviewed a variety variety of interventions interventions.

– Cognitive/emotion‐oriented interventions (10 reports)

– Sensory stimulation interventions (12 reports)

– Behavior management techniques (3 reports, 2 primary s

– Exercise (3 reports)

– Ani l ma ‐assi d ste th i erap es (9 prospective studi ) es– Interventions for wandering (5 reports)– Agitation Agitation (1 report, 1 primary primary study)
Evidence‐based Synthesis

Program (ESP)

Results

• Key Question #1: How do non‐pharmacological treatments of b

symptoms compare in effectiveness with each other, with pharm

approaches, and with no treatment?
Evidence‐based Synthesis

Program (ESP)

Cognitive/Emotion‐oriented Interventi

• Reminiscence Therapy

– Reminiscence therapy involves the discussion of past act

and experiences experiences with another another person or a group of peop

– Two previous systematic reviews identified seven small r

control trials (RCTs) of reminiscence therapy.

– This limited body of evidence does not support the use o

reminiscence therapy for the treatment of behavioral sym

dementia
Evidence‐based Synthesis

Program (ESP)

Cognitive/Emotion‐oriented Interventi

• Simulated Presence Therapy (SPT)

– SPT involves the use of audiotapes made by family memb

containing containing a scripted scripted conversation conversation about cherished cherished mem

mem

the patient’s life.

– Overall, well‐conducted studies are lacking.

– The evidence that SPT reduces behavioral symptoms of d

inconsistent, and SPT may have adverse effects in some p
Evidence‐based Synthesis

Program (ESP)

Cognitive/Emotion‐oriented Interventi

• Validation Therapy

– Validation therapy is intended to give the individual an o

resolve resolve unfinished unfinished conflicts conflicts by encouraging encouraging and validatin

validatin

of feeling.

– Four systematic reviews examined the effects of validatio

three RCTs as well as other study designs, and found mix

– Overall, there is insufficient evidence to draw conclusion

efficacy efficacy of validation validation therapy therapy for behavioral behavioral symptoms symptoms, d

d

and emotional state associated with dementia.
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Acupuncture

– Acupuncture is an ancient Chinese treatment that has be

over 3 000 , years.

– One systematic review found no rigorously conducted RC

– There is no good q y ualit evidence indicating benefit or h

acupuncture for the treatment of behavioral symptoms f
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Aromatherapy

– Aromatherapy consists of the use of fragrant oils from pl

been used to promote promote sleep and reduce behavioral behavioral symp

symp

individuals with dementia.

– Overall, there is insufficient evidence that aromatherapy 

effective treatment for agitation and other behavioral sy
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Light Therapy

– Light stimulation aims to improve the circadian disturban

sleep‐wake cycles experienced experienced by individuals individuals with deme

deme

– Two systematic reviews identified six studies, including tw

– Although some studies found beneficial effects of bright 

on agitation and nocturnal restlessness, studies were genby small sample size and poor quality. The limited body oinsufficient insufficient to draw definitive definitive conclusions conclusions about the effe

effe

light therapy in managing sleep, behavior, or mood distu

associated with dementia.
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Massage and Touch

– Massage and touch therapies include a range of interven

from professional professional massage massage to informal informal hand patting patting and 

“calming touch.”

– A systematic review identified two small RCTs that report

calorie and protein intake in a study that compared touc

with verbal encouragement during meals to verbal encou

alone, and reduced agitation in a study that compared ha

with calming music and with no treatment.

– This limited body of evidence suggests that hand massag

therapy may have beneficial beneficial effects effects.
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Music Therapy

– Music interventions range from activities administered b

professional music therapist to the presentation of recorcaregivers to patients.

– Four systematic reviews examined a variety of study desi

RCTs reported reported reduced reduced aggression aggression, agitation agitation, and wande

wande

listening to music; and other studies found similar reduct

behavioral symptoms, although there was no evidence o

effects. All studies were li i d m te by methdl i l odological issues

– Overall, well‐conducted studies are lacking, but music int

have potential for reducing agitation in patients with dem

short term.
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Snoezelen Multisensory Stimulation Therapy

– Multisensory stimulation (MSS), otherwise known as Sno

therapy therapy, combines combines the therapeutic therapeutic use of light, tactile tactile su

su

and aroma. MSS is based on the premise that neuropsycsymptoms may result from periods of sensory deprivatio

– There were six RCTs identified among four systematic rev

– Although the evidence did not consistently demonstrate 

effect of MSS therapy therapy on behavioral behavioral symptoms symptoms, prelimina

prelimina

short‐term benefits and the reported pleasantness of the 

suggest that future research is warranted.
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions

• Transcutaneous Transcutaneous Electrical Electrical Nerve Stimulation Stimulation (TENS)

– TENS is a non‐invasive analgesic technique that is most o

pain control and occasionally for neurological and psychi

conditions, such as drug/alcohol dependency, headaches

depression.

– A systematic systematic review combined combined data from three RCTs in in

in

dementia and found no significant effects on sleep distur

behavioral symptoms, evaluated immediately after treat

week follow‐up.

– Although some short‐lived improvements in neuropsycho

symptoms of dementia have been observed with TENS, d

conclusions on the possible benefits of this intervention made. 
Evidence‐based Synthesis

Program (ESP)

Behavior Management Techniques

– Behavior management techniques include a variety of be

interventions (e.g., functional analysis of specific behavioeconomies, habit training, progressive muscle relaxation

communication training, behavioral or cognitive‐behavio

various individualized behavioral reinforcement strategie

– Findings Findings from three systematic systematic reviews reviews including including seven R

additional more recent trials provide some support for bmanagement techniques as effective interventions for be

symptoms symptoms of dementia dementia. However However, mixed study results results, th

specific interventions across studies, and methodologica

many studies suggest that additional research in this are

results is warranted.
Evidence‐based Synthesis

Program (ESP)

Other Psychosocial Interventions

• Animal‐assisted Therapy

– There were no RCTs evaluating the effectiveness or harm 

therapy.

– Nine non‐randomized studies demonstrated decreases in 

disrupted behaviors, increases in social and verbal intera

decreases decreases in passi it passivity, and increases increases in n tritional nutritional intake

– The findings suggest that pet therapy has potential for be

more rigorous studies are needed to establish benefit, ha

feasibility for implementation in VA settings.
Evidence‐based Synthesis

Program (ESP)

Other Psychosocial Interventions

• Exercise

– Three systematic reviews of 59 studies showed inconsiste

exercise exercise interventions interventions on behavioral behavioral symptoms symptoms and func

func

Variations in intensity of exercise intervention, severity obaseline, and outcome measures make it difficult to draw 

conclusion conclusion. Many of the included included studies studies were small and 

rigorous methodology.

– The most consistent evidence showed that exercise did i

duration and decrease nighttime awakenings. While the 

improved sleep on distal health outcomes remains uncer

may be an additional benefit to caregivers who are dispr

affected by dysfunctional sleep.
Evidence‐based Synthesis

Program (ESP)

Interventions Targeting a Specific Behavioral Symptom: 

• No RCTs on eff t ec s of subj ti ec ve vi l sua b i arr ers, such as mirro

camouflage of doors/doorknobs, and concealment of view th

windows.

• Two RCTs determined that exercise and walking therapies ha

on wandering.

• No evidence evidence is available available on the effects effects of wander gardens gardens.

• Tracking devices, motion detection devices, and home alarm

generally effective in detecting wandering and locating lost p

non‐randomized studies.

• Evidence about the effects of sensory stimulation therapies, 

aromatherapy, and music on wandering, is scant and inconcl
Evidence‐based Synthesis

Program (ESP)

Interventions Targeting a Specific Behavioral Symptom

• One syst ti ema c review of agit ti a on id tifi d entified 14 RCTs.

• A meta‐analysis of three sensory interventions (aromatherap

bath, calming music, hand massage) showed a significant de

agitation, but there was substantial variability in the type of 

duration of exposure, and outcomes measured.

• Other interventions interventions (social (social contact contact, environmental environmental modificat

modificat

training, behavior therapy) showed no effects on agitation.

• One recently conducted primary study suggested to us by rev

provided preliminary support for the effectiveness of system

individualized intervention in decreasing agitation, though a 

assessor blinding to condition limits the validity of these find
Evidence‐based Synthesis

Program (ESP)

Interventions Targeting a Specific Behavioral Symptom: In

Sexual Behavior

• There were no systematic reviews that examined the topic o

inappropriate sexual behavior among individuals with demen

• Currently, the effectiveness of non‐pharmacological treatme

inappropriate sexual behavior is unknown.
Evidence‐based Synthesis

Program (ESP)

Comparative effectiveness among non‐pharmaco

interventions and between p g harmacological and 

pharmacological approaches

• None of the systematic reviews captured in our search identi

to‐head trials that directly compared effectiveness among di

pharmacological interventions, or between non‐pharmacolog

pharmacological treatments.
Evidence‐based Synthesis

Program (ESP)

Recap of Results

• Overall Overall, some promising promising results results, yet support support for most interventions interventions 

inadequate and plagued by methodological limitations

• Stimulation/sensory approaches show more promise than cognitive

ori td en e approaches b t u there are no h d ea ‐to‐h d ea comparisons

• Behavior management techniques need additional validation, thou

research shows promise

• Some support for positive effects of exercise on sleep and physical 

outcomes

• Targeted, tailored, individualized, multi‐faceted, and flexible approa

most promise

• Potentially fewer and less severe harms associated with non‐pharm

versus p g harmacological interventions
Evidence‐based Synthesis

Program (ESP)

Results

• Key Question #2: How do non‐pharmacological treatments of b

symptoms compare in safety with each other, with pharmacolog

approaches, and with no treatment?
Evidence‐based Synthesis

Program (ESP)

Cognitive/Emotion‐oriented Interventio

• One study found that simulated presence therapy increased 

disruptive behaviors in some patients.

• Reality orientation has been observed by caregivers to increa

fear, and agitation in individuals with later stages of dementi
Evidence‐based Synthesis

Program (ESP)

Sensory Stimulation Interventions:

• For some individuals, the increased stimulation from sensory 

therapies such as music therapy and massage/touch therapy 

i d ncreased agit ti a on and aggression.

• Consideration of the individual preferences in the use of thes

should be emphasized.
Evidence‐based Synthesis

Program (ESP)

Behavior Management Techniques:

• None of the systematic reviews nor the primary studies revie

documented any patient harm or safety concerns resulting fr

bh i e av or management t hi ec n ques.
Evidence‐based Synthesis

Program (ESP)

Animal‐assisted Therapy:

• The American Veterinary Medical Association guidelines desc

physical and emotional harms associated with animal‐assiste

the act l ua i id nc ence of harms has not been well‐st di d u e .

• Theoretical harms include human injury, zoonotic disease, al

reactions, and the risk of grief reaction if an animal dies.
Evidence‐based Synthesis

Program (ESP)

Exercise:

• Potential harms of exercise programs include the increased r

physical injuries, but risks associated with exercise have not b

st di d u e .
Evidence‐based Synthesis

Program (ESP)

Various interventions targeting a specific be

symptom:

• The HTA report noted the potential risk of a false sense of se

caregiver associated with the use of tagging/tracking devices 

wandering.

• Other systematic systematic reviews reviews included included in our search did not iden

iden

on adverse effects of interventions that target wandering or 
Evidence‐based Synthesis

Program (ESP)

Comparative Safety among Non‐pharmaco

Interventions Interventions and between between Pharmacological Pharmacological 

pharmacological Approaches

• None of the systematic reviews captured in our search identi

to‐head trials that directly compared safety among different 

ph lil armacological i t ti n erventions, or b t e ween non‐ph l

armacolog

pharmacological treatments.
Evidence‐based Synthesis

Program (ESP)

Results

• Key Question #3: How do non‐pharmacological treatments of b

symptoms compare in cost with each other, with pharmacologic

approaches, and with no treatment?
Evidence‐based Synthesis

Program (ESP)

Costs

• No direct evidence on the cost‐effectiveness of specific interv

• GPS tracking devices and other monitoring systems are costly

potential increases in patient safety and caregiver peace of m

associated with the use of these devices are notable.

• Training Training and veterinary veterinary care associated associated with animal‐assisted assisted 

costly. Some options such as aquariums may be less expensiv

individualized approaches.

• F th ur er st di u es are need de to dt i e erm ne the cost‐b fit ene s, h

feasibility of these and other non‐pharmacological interventi
Evidence‐based Synthesis

Program (ESP)

Future Research Priorities

1) Double blind, RCTs2) Research replicated replicated across labs3) Head to head comparisons providing direct evidence compa

interventions interventions to other interventions interventions and to pharmacologica

pharmacologica

4) VA feasibility and implementation research5) Cost effectiveness research
Evidence‐based Synthesis

Program (ESP)

Discussion

• Where do we go from here as clinicians?• How do we take information from this report and im

appropriate policy?

• How should we design necessary research to addre

in our knowledge?
Evidence‐based Synthesis

Program (ESP)

Discussion

• Re‐introduction of discussants• Overview of the Dementia Steering Committee acti

information about the National Alzheimer’s Project 

Cooley)

• Overview of current VA Office of Mental Health act

goals including roll out of the STAR‐VA program (Bra

Greg Hinrichsen)
STAR‐VA Pilot: A Multi‐Compone

Psychosocial Approach to Managi

Managi

Challenging Dementia‐Related Beha

Bradley Karlin, Ph.D.

Office of Mental Health Services

VA Central Office
Bridging Science and Prac

STAR‐VA Pilot Dissemination I

• VA workg p rou charged to review literature on p 

s 

approaches to managing dementia‐related behav

– Efficacy– Utility with Veteran population– Implementation issues and feasibility

• Recommendation and decision made to develop p

to disseminate adapted version of STAR (Teri et al., 

CLCs

– STAR originally developed for assisted living residences

• Subsequent content development workgroup form

STAR intervention and training materials for VHA

– In conjunction with Dr. Linda Teri
STAR‐VA Content Develo

Develo

Workgroup

Ali Asghar‐Ali, MD

David Bass, MD

Bradley E. Karlin, 

, Douglas W. Lane, 

Jan S. Cavanaugh,Steven M Crocker PhD

g ,

Rhonda R. Maure

Steven M. Crocker, PhD Jocelyn McGee MKimberly Curyto, PhDMi h l D l PhD

Jocelyn McGee, MElizabeth S. Suthe

Michael Drexler, PhD Li d T i PhDLori B. Highberger, MD

Linda Teri, PhDKelly M. Trevino, P

Gregory A. Hinrichsen, PhD
Overview of STAR‐VA

• STAR‐VA is an interdisciplinary interdisciplinary behavioral behavioral approa

approa

managing challenging dementia‐related behavio

– CLC MH Providers Providers work with “Staff Partners Partners” (p

(p

nursing staff) in development and implementa

behavioral intervention plan

• CLC MH Provider: Primary interventionist and behav

coordinator

• “Staff Partners : Partners”: Inform development development of behavior behavior pla

contribute to implementation of plan

– Individualized and systematic
Core Components Components of STAR

1. Id if i Identifying and ch i ang ng antecedents to and

consequences of challenging behaviors (ABC

2. Increasing pleasant events3. Promoting effective communication and cre

reali ti s c expect ti a ons of i di id l individuals with d 

em
Evidence‐based Synthesis

Program (ESP)

Discussion

• Where do we go from here as clinicians?• How do we take information from this report and im

appropriate policy?

• How should we design necessary research to addre

in our knowledge?
Evidence‐based Synthesis

Program (ESP)

Questions?

If you have further questions,

feel free to contact:

Maya O’Neil, Ph.D.

503 220 8262 503.220.8262 x54522

maya.oneil@va.gov

oneilm@ohsu.edu

The full report and cyberseminar presentation is available on the E

http gp p ://www.hsrd.research.va.gov/publications/esp/
6/23/2011 12:00pm ESP Report: Non-Pharmacological Interventions for 

Behavioral Symptoms of Dementia

Spotlight on Evidence-based 

Synthesis Program

Cooley, Susan

Hinrichsen, Gregory

Karlin, Bradley

O'Neil, Maya

Q&A Submitted: 

Question: Has there been any evidence for using creative arts as a treatment approach to BPSD?

Answer: We did not find any direct evidence that met our criteria for inclusion (good quality systematic review); however, 

some of the articles mentioned art-related activities as part of behavior management technique interventions as they can be 

very reinforcing for some individuals. Also, the music literature is very related to the creative arts and these types of 

interventions demonstrated some positive results.

Question: Our geriatric clinical team support Veterans staying in their homes for as long as possible. To do this means 

supporting the caregiver along the way. Although we use behavioral approaches all the time we do need to rely on atypical 

antipsychotics for the short term when a Veteran's behavior is unmanageable to the caregiver ( e.g. up all night pulling things 

out of drawers, attempts to hit caregiver, etc.). The evidence does not support utilizing these medications for behavior 

management in dementia. We need more research on these medications and their use in dementia. Other medications we 

have tried in the community setting have not worked as well. Are there any key funded studies going on currently to compare 

different medications for agitation in dementia?

Answer: I’m not an expert in this area, but the research I’m familiar with comes from the Cochrane database of systematic 

reviews: www.cochrane.org. I found some reports there suggesting that some drugs are likely to be efficacious. Here are the 

relevant reviews that I am aware of: http://www2.cochrane.org/reviews/en/ab008191.html, 

http://www2.cochrane.org/reviews/en/title_06042972373138472468100917122124.html, 

http://www2.cochrane.org/reviews/en/ab003945.html, http://www2.cochrane.org/reviews/en/ab004990.html, 

http://www2.cochrane.org/reviews/en/ab002852.html http://www.annals.org/content/148/5/379.full

http://www.annals.org/content/148/5/370.full http://www.guideline.gov/syntheses/synthesis.aspx?id=16414

Question: did light study studies measure impact on sun dowing sx?

Answer: Sun-downing was not mentioned in the reviews that we examined, likely because this term is hard to define, it’s not 

part of a DSM diagnosis, and it has not been well researched. The light studies we examined, however, didn’t mention sundowning.

Question: Do memory-enhancers (like Aricept, Namenda, or Cognex) do really work? 

Answer: I have never seen any discernible cognitive changes or memory-enhancement in my patients. I’m not an expert in 

this area, but the research I’m familiar with comes from the Cochrane database of systematic reviews: www.cochrane.org. I 

found some reports there suggesting that some drugs are likely to be efficacious, particularly with Alzheimer’s type 

Dementia. Here are the 3 relevant reviews that I am aware of: http://www2.cochrane.org/reviews/en/ab005593.html, 

http://www2.cochrane.org/reviews/en/ab001191.html, http://www2.cochrane.org/reviews/en/ab001011.html. 

Question: how do token economies work in patients with impairments in memory and learning?

Answer: This really depends on the individual and the extent of memory and learning impairment. Sometime a very simple, 

basic token economy can be effective even when there is significant cognitive impairment; however, you bring up a good 

point that sometimes the severity of memory impairment precludes the use of this particular type of strategy, This, like many 

other behavior management techniques, often requires attempting variations on the standard intervention to determine what 

might be effective for each individual.

Question: did the review focus on the level or stage of dementia? There can be wide variation across the disease 

progression which could confound the response to interventions.

Answer: You are right—there is wide variation. We did not limit by level or stage of dementia for the purpose of this review, 

nor did any of the studies we found. It is likely, however, that an individualized approach to treatment might be needed to 

address individual differences in progression and severity of symptoms.

Question: what was the cause of death in those deaths associated with antipsychotics? 

Answer: Though I am not an expert in this area, I do know of some recent research suggesting that antipsychotic 

medications (both typical and atypical), particularly when prescribed to elderly individuals, is associated with increased risk 

of death. Some recent citations include: http://www.ncbi.nlm.nih.gov/pubmed/17687661, 

http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1991.tb01421.x/pdf, 

http://canadianmedicaljournal.ca/cgi/content/full/176/5/627, and 

http://ajp.psychiatryonline.org/cgi/content/abstract/158/11/1774 . 

Question: are there any studies looking at some of the principles of Positive Behavior Support?
6/23/2011 12:00pm ESP Report: Non-Pharmacological Interventions for 

Behavioral Symptoms of Dementia

Spotlight on Evidence-based 

Synthesis Program

Cooley, Susan

Hinrichsen, Gregory

Karlin, Bradley

O'Neil, Maya

Answer: None that we found, though PBS principles are likely included in many of the Behavior Management Strategies that 

we examined.

Question: How do we access the STAR-VA manual?

Answer: STAR-VA manual is currently unavailable for distribution since we’ve just begun the assessment of it initial 

implementation.

Question: Is there a version of STAR-VA adapted to work with Caregivers in their homes?

Answer: STAR-VA is for work with formal caregivers. However, REACH-VA is an effort that was developed for 

implementation with family caregivers.