Psychosocial interventions for people with dementia: a synthesis of systematic reviews

Figures & data

Figure 1. PRISMA Flowchart.

Table 1. AMSTAR scores of the 22 reviews.

Review	1	2	3	4	5	6	7	8	9	10	11	Total
Alves	Y	Y	Y	Y	N	N	N	Y	Y	Y	Y	8
Bahar-Fuchs	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	11
Blankevoort	Y	CA	Y	N	N	Y	Y	Y	N/A	N	Y	6
Burton	Y	CA	Y	N	N	Y	Y	Y	NA	N	Y	6
Carrion	Y	Y	Y	Y	N	Y	Y	Y	N/A	N	Y	8
Cooper	Y	Y	Y	N	N	N	Y	Y	N/A	Y	Y	7
Farina	Y	CA	N	N	N	N	Y	Y	N/A	Y	Y	5
Forbes	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	11
Garcia-Casal	Y	CA	N	N	N	Y	Y	Y	Y	N	Y	6
Huntley	Y	Y	Y	Y	N	N	N	Y	Y	Y	Y	8
Law	Y	Y	Y	N	N	Y	Y	Y	N/A	Y	Y	8
Leung	Y	Y	Y	N	Y	Y	N	Y	N/A	Y	Y	8
Livingston	Y	Y	Y	Y	N	Y	Y	Y	Y	Y	Y	10
Ohman	Y	CA	Y	N	N	Y	Y	Y	N/A	N	N	5
Orgeta	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	11
Pitkälä	N	CA	Y	N	N	Y	Y	Y	N/A	Y	N	5
Potter	Y	Y	N	N	N	Y	Y	Y	Y	N	Y	7
Rao	Y	CA	Y	Y	N	N	N	Y	Y	N	N	5
Regan	Y	CA	Y	Y	N	N	Y	Y	N/A	N	Y	6
Spector	Y	CA	Y	N	N	Y	Y	Y	N/A	N	N	5
Testad	Y	Y	Y	N	N	Y	Y	Y	N/A	N	Y	7
Woods	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	11

AMSTAR Items are: (1) a priori design; (2) duplicate study selection and data extraction; (3) comprehensive literature search; (4) inclusive publication status; (5) included studies provided; (6) characteristics of included studies provided; (7) quality assessment of studies; (8) study quality used appropriately in formulating conclusions; (9) appropriate methods used to combine studies; (10) publication bias assessed; and (11) conflict of interest stated. Scores: C, can't answer; N, no; NA, not applicable; Y, yes. (Adapted from Jaspers et al., 2011)

Table 2. Characteristics of included reviews.

Review	Review focus	No. of studies	No. of participants	Interventions	AMSTAR
Alves (2013)	Cognition, Cost-effectiveness	4 RCTs	68	Cognitive Cognitive intervention: Memory training (45 min × 6 weeks), or ‘attention stimulating activities’ (1 h × 5 weeks) or CT 1 h × 2/week × 6 months, or CST 45 min x 2/week × 10 weeks.	8
			65	Cognitive Comparison condition: Psycho-education (45 min × 6weeks) or conversation/recitation/watching videos (1 h × 5 weeks) or social support (1 h/week × 6 months), or conversation/support (45 min × 2/week × 10 weeks).
Bahar-Fuchs (2013)	Cognition, Mood, ADL	11 RCTs	322 + 198 dyads	Cognitive CT included attention and reading, active cognitive stimulation, individually tailored memory training exercises, retrieval training, memory strategies, use of computerised training package, name-face learning. 30min-1hr × 1-6/week × 4-24 weeks.	11
		1 RCT	69	Cognitive CR focusing on personally meaningful goals. Provision of practical aids and individualised strategies. 1hr weekly x8 weeks.
Blankevoort (2010)	Strength, Mobility, ADL	16 (10 RCTs)	642	Exercise Aerobic exercises, strengths / balance/ resistance / coordination training, walking. 30-60 min × 2-5/week × 3 weeks -12 months.	6
Burton (2015)	Falls prevention	4 (3 RCTs)	336	Exercise HLDR, strength, balance, endurance/mobility training, walking, home visits and supervision, WEBB. 1-5/week × 3-12 months.	6
Carrion (2013)	Cognition	9 RCTs	571	Cognitive RO 30-60 min × 2-3/week. Total 14-78 sessions. RO only or RO with other activities.	8
		8 RCTs	367	Cognitive Skills Training 30min-2.5 h × 1-5/week × 2 weeks-6 months. Various interventions including computerised exercises, cognitive rehabilitation training, word-list remembering, face-name association, basic ADL training, problem solving and conversation.
Cooper (2012)	Quality of life	20 RCTs	420	Familycarer Education and behaviour management, environment modification, communication. Face to face and telephone interventions.	7
			191	Dyadic Individually tailored activities delivered by OTs aimed mainly at carer but included people with dementia. Home visits and phone calls.
			201	Cognitive Group CST in the community or in care homes.
Farina (2014)	Cognition	6 RCTs	171	Exercise Walking, aerobic fitness, strength training. 30min– 2hr × 1/week-daily × 12-24 weeks.	5
Forbes (2013)	Cognition, ADL, Behaviour, Mood	16 RCTs	937	Exercise Seated exercise, walking, physical activities to promote socialisation, strength training. 2/week–daily × 2 weeks-12 months.	11
García-Casal (2017)	Cognition, Mood	7 RCTs + 2 CCS + 2 B/A + 1 MM	700	Cognitive Computer-based interventions (CR, CT, CS, CRC). 29-210 min × 1-4/week × 10-72 sessions. CR included neuropsychological training, social competence tasks, orientation & memory. CT focused on language fluency, memory & vissuospatial abilities. CS included interactive multimedia system, integrated stimulation programme & social activation. CRS included interactive computer games for memory, problem-solving & psychomotor skills.	6
Huntley* (2015)	Cognition	23 RCTs (CS)	1570 (875+ 685)	Cognitive CS 30 min-3.5 h × 1-6/week × 4-104 weeks. Individual session 40-60 min x1-6/week × 6 weeks-6 months.	8
		4 RCTs (CT)	87 (45+ 42)	Cognitive CT 20-60 min × 2-6/week × 4 weeks-6 months.
		2 RCTs (CR)	217	Cognitive CR 60 min × 1/week × 12 or 22 weeks. Individual session 40 min × 1/week × 22 weeks.
		7 RCTs (mix)	197 (101+ 96)	Cognitive Mixed CT and stimulation: session 45min-4 h × 1-6/week × 5-24 weeks.
Law (2014)	Cognition, Exercise	3 RCTs + 2 non RCTs	322 with cognitive impairment	Cognitiveand Exercise Combined cognitive and exercise intervention. Dual-task training for 4 studies. 30 min-2 hrs × 3-12 months.	8
Leung (2015)	Depression QoL	2 RCTs	169	Social Depression. Multimodal intervention of exercises, CBT, support groups 90 min/week × 20 weeks (study 1) or structured social support group (educational seminars and discussions) 90 min/week × 9 weeks (study 2)	8
Livingston (2014)	Agitation	33 RCTs	3116	Social and Psychological Effective interventions: Activities, ‘Music Therapy’, therapeutic touch. Staff training (Person-Centred Care and communication skills, Dementia Care Mapping) also important. No evidence for light therapy or aromatherapy.	10
Öhman (2014)	Cognitive perfor-mance	22 (MCI & 14 (dementia)	1021 (MCI), 678 (dementia)	Exercise Exercise groups and walking most common. Session: 30min-2 hr. × 1-5/week × 6-52 weeks.	5
Orgeta (2014)	Anxiety, Depression	6 RCTs	439	Psychological Multimodal CBT (Tai Chi, CBT and support group) for 20 weeks. Interpersonal therapy 50 min x6 weeks. CBT 60 min x10 over 15 weeks. CBT 30-60 min × 3 months plus telephone appointments months 3-6. Counselling 30 min x3/week × 16 weeks. Multi-modal intervention including counselling sessions, educational courses and telephone support calls.	11
Pitkälä (2013)	Mobility, Physical functioning	20 RCT	1378 (575 residential & 803 home)	Exercise Walking, strength training, balance/coordination training or functional exercises. Included multimodal programmes. Session: 30min-1 h × 2/week-daily × 2 weeks-12 months.	5
Potter (2011)	Physical functioning, QoL, Depression	13 RCTs	896	Exercise Strength, flexibility or balance training, walking, Tai Chi. Group exercise common. Session 30-75 min × 2/week-daily × 12 weeks–12 months (majority: 12-16 weeks).	7
Rao (2014)	ADL, Physical functioning, Cognition, Mood	6 RCTs	446	Exercise Walking, aerobic programme, strength training, balance exercises.	5
Regan (2013)	Anxiety, Depression Adjustment	7 RCTs & 8 pre-post	819	Psychological Depression. Problem solving therapy (3 studies), CBT (2), Psychological: Adjustment. Recovery orientated intervention (1), Brief psychodynamic therapy (1), CBT (1), Psychotherapy (2), Multimodal interventions (4), Community-based group interventions (2)	6
Spector (2012)	Cognition	11 RCTs	460	Cognitive CT 30-90 min × 1-6/week × 4-24 weeks. Attention, memory training, problem solving.	5
		7 RCTs	583	Cognitive CS 30-min-3.5 h × 2-4/week × 5 weeks-1 year. Orientation, reminiscence, cognitive exercises.
Testad (2014)	BPSD	40 (26 RCTs)	5043	Social and Psychological Reminiscence (6 studies), personalised music (7), personalised pleasant activities with or without social interaction (10), validation therapy (2), personalised physical activity (12), person-centred care training and practice development (3). Intervention 30 min – 4 hrs × 1/week – 2/day for 1-78 weeks.	7
Woods (2012)	Cognition, Social	15 RCTs	718	Cognitive CS group or with family, 30-60 in, 1-5/week, 4-25 weeks.	11

*A total of 33 RCTs were included in Huntley's review. Three studies included two interventions: CS & CR (2 studies) and CS & MCTS (1 study)

B/A = Before and After study. BMT = Behavioural Management Therapy. CBT = Cognitive Behavioural Therapy. CCS = Case Control Study. CR = Cognitive Rehabilitation. CRC = Cognitive Recreation. CS = Cognitive Stimulation. CST = Cognitive Stimulation Therapy. CT = Cognitive Training. HLDR = health lifestyle dementia respite. MCI = Mild Cognitive Impairment. MCTS = Mixed Cognitive Training and Stimulation. MM = Mixed Methods study. RO = Reality Orientation. WEBB = Weight-Bearing Exercise for Bette Balance programme.

Table 3. Effects of the interventions according to key domains.

Domains	Review	Type of Intervention	Effect sizes (95% Confidence Interval) MD = Mean Difference. d = Cohen's d. g = Hedges’ g. SES = standardised effect sizes.	n. of studies in ES	Review conclusion
Physical outcomes	Blankevoort (2010)	Exercise	Gait speed (normal) d = 0.29 (-0.11, 0.50)	6	Moderate overall effects found in studies with good quality. Multicomponent interventions of 45-60 min × 3/week x12 weeks or more recommended.
			Gait speed (fast) d = 0.14 (0.10, 0.19)	2
			Endurance d = 1.08 (0.31, 3.79)	5
			Functional mobility d = 0.28 (-0.25, 2.37)	6
			Lower-extremity strength d = 0.85 (-0.04, 3.14)	7
			Balance d = 1.76 (-0.24-3.59)	5
	Burton (2015)	Exercise	Number of falls MD -1.06 (-1.67, 0.46). Risk ratio 0.68 (0.55-0.85).	3	Falls prevention interventions training and progress in intensity over time can assist in the reduction of falls.
	Pitkälä (2013)	Exercise	No meta-analysis	N/A	Intensive physical rehabilitation enhances mobility, physical functioning improve after a long period.
	Potter (2011)	Exercise	TUG MD -1.39 (-2.59, -0.19), Z = 2.27 (p = 0.02)	3	High intensity physical interventions improve physical function.
			6-minute walk test MD 47.10 (-19.78, 113.97) Z = 1.38 (p = 0.17)	2
			Walking speed MD 0.06 (0.01, 0.10) Z = 2.67 (p = 0.008)	4
			Berg Balance MD 3.40 (1.08, 5.72) Z = 2.87 (p = 0.004)	2
	Rao (2014)	Exercise	Physical function (combined) d = 0.53 (0.24, 0.82), Z = 3.54 (p = 0004)	6	Average effect size was moderate but was statistically significant.
Cognitive outcomes	Alves (2013)	Cognitive	Cognitive Intervention: MMSE MD 0.87 (0.26, 1.48) Z = 2.80 Neuropsychiatric assessment (1 RCT) MD 2.06 (-2.91, 1.21) Memory complaints (1 RCT) MD 19.90 (1.87, 37.93)	3	Significant changes only in global cognitive functioning. One RCT suggests cognitive intervention to be cost-effective
	Bahar-Fuchs (2013)	Cognitive CT	Global measure of cognition d = 0.10 (-0.21, 0.40) Z = 0.62 (p = 0.53)	6	Statistically no positive or adverse effects.
	Carrion (2013)	Cognitive RO	No meta-analysis	N/A	RO effective for overall cognitive function but only 6 out of 9 reached statistical significance.
		Cognitive Skills	No meta-analysis	N/A	Positive effects were observed but only 1 good quality RCT reached statistical significance.
	Farina (2014)	Exercise	d = 1.12 (0.37, 1.88), Z = 2.91 (p = 0.004)	4	Positive effect on rate of cognitive decline in AD.
	Forbes (2013)	Exercise	d = 0.55 (0.02, 1.09), Z = 2.03 p = 0.04)	8	Significant impact on improving cognitive functioning, but substantial heterogeneity.
			d = 0.31 (-0.11, 0.74) (moderate-severe dementia excluded), Z = 1.45 (p = 0.15)	7
	García-Casal (2017)	Cognitive CRC, CR, CS, CT	(1) Cognition (CRC, CR, CS, CT combined) d = 0.69 (0.37, 1.02). (CR only) d = 0.54 (0.14, 0.94); (2) Computer-based intervention vs. non computer-based intervention (CR, CS, CT combined) d = 0.48 (0.09, 0.87). (CR only) d = 0.56 (0.04, 1.07)	9	Overall moderate effects on cognition.
	Huntley (2015)	Cognitive CS	MMSE g = 0.51 (0.35, 0.66) Z = 6.23 p<0.001 compared to non-active controls.	17 NAC	Cognitive stimulation improves MMSE and ADAS-Cog scores though ADAS-Cog changes are not clinically significant.
			ADAS-Cog g = -0.26 (-0.44, -0.08) Z = 2.82 p = 0.005. 3-months follow-up: 0.796 (0.052, 1.539).	9 NAC
			g = 0.35 (0.06, 0.64) Z = 2.34 p = 0.019 compared to active controls.	3 AC
		Cognitive CT	MMSE g = 0.22 (-0.754, 1.180) Z = 0.44 p = 0.658.	3 AC	No significant improvements on general cognition outcomes.
		Cognitive CR	No meta-analysis	N/A
		Cognitive MCTS	g = 0.447 (-0.568, 1.462) Z = 0.86 p = 0.388	Active
			g = 0.253 (-0.179, 0.686) Z = 1.15 p = 0.251	NAC
	Law (2014)	Cognitive and Exercise	(Not meta-analysis) Dual-task d = 0.99. Attention (d = 0.24-1.57) in MCI and AD. General cognitive functions (d = 0.11-0.63), language (d = 0.22-0.62), memory (d = 0.16) and 5/6subjective rating of functional status (d = 0.59) in MCI.	4	Significant improvements in general cognitive functions, memory, attention, but lack comparison with active control groups.
	Öhman (2014)	Exercise	No meta-analysis	N/A	Impact of exercise intervention for cognitive performance is inconsistent, but study quality often poor.
	Rao (2014)	Exercise	(Cognition and mood combined) d = 1.23 (-1.06, 3.53), Z = 1.05 (p = 0.29)	4	Exercise improved overall cognitive function, but not statistically significant.
	Spector (2012)	Cognitive CT	No meta-analysis	N/A	Unclear which domains are effective.
		Cognitive CS	No meta-analysis	N/A	Evidence for general cognitive enhancement.
	Woods (2012)	Cognitive CS	Overall: d = 0.41 (0.25, 0.57), Z = 5.04 (p<0.00 001)	14	Significant benefits to cognitive function, maintained at follow-up.
			ADAS-Cog MD 2.27 (0.99, 3.55) Z = 3.48 (p = 0.0005)	7
			MMSE MD 0.64 (0.17, 1.10) Z = 2.69 (p = 0.007)	2
Mood	Bahar-Fuchs (2013)	Cognitive CT	Self-reported mood 0.03 (-0.34, 0.41), Z = 0.16 (p = 0.87)	4	Not associated with positive or negative effects in relation to any reported outcomes.
		Cognitive CR	Self-reported mood 0.24SD lower	1	The evidence from a single study is not sufficient to draw a conclusion even though the study quality is high.
			Caregiver self-reported mood mean change 1.22 higher
	Forbes (2013)	Exercise	Depression MD 0.14 (-0.07, 0.36), Z = 1.29 (p = 0.20)	5	No significant effect of exercise on depression.
	García-Casal (2017)	Cognitive	Depression d = 0.47 (0.16, 0.78). Anxiety d = 0.55 (0.07, 1.04).	9	Small to moderate effects on depression and anxiety.
	Leung (2015)	Social	No meta-analysis. GDS d = 0.36 (study 1). No significant differences (study 2).	1	Support groups may help reduce depression but evidence is limited.
	Orgeta (2014)	Psycho-logical	Depression d = -0.22 (-0.41, -0.03), Z = 2.30 (p = 0.02)	6	Depression and clinician-rated anxiety improved. No significant changes in self-rated or carer rated anxiety.
			Anxiety MD-4.57 (-7.81, -1.32), Z = 2.76 (p = 0.006)	2
			Anxiety self-rating: d = 0.05 (-0.44, 0.54) Z = 0.21 (p = 0.83)	2
			Anxiety carer (NPI-A): MD -2.40 (-4.96, 0.16) Z = 1.83 (p = 0.07)	1
	Potter (2011)	Exercise	No meta-analysis	N/A	No evidence whether physical activity will prevent or reduce depression in people with dementia.
	Rao (2014)	Exercise	No meta-analysis on mood only	N/A	Two studies reported the effects of exercise on mood but not statistically significant.
	Regan (2013)	Psycho-logical	No meta-analysis	N/A	Problem solving and modified CBT may be beneficial.
	Testad (2014)	Social & Psycho-logical	No meta-analysis	N/A	Reminiscence effective to reduce depression.
Behaviour	Livingston (2014)	Social	Agitation: SES (estimated) 0.3-1.8 (immediately), 0.2-2.2. (follow-up)	5	Person-Centred care, communication skills training and adapted dementia care mapping decreased agitation immediately and at follow-up.
		Psycho-logical	Agitation: SES (estimated) (0.5-0.6)	8	Activities and music therapy by protocol decreased agitation immediately but not at follow-up.
	Testad (2014)	Social & Psycho-logical	No-meta analysis	N/A	Pleasant activities with or without social interaction reduce agitation. Evidence for the effects of music on agitation inconsistent.
	Forbes (2013)	Exercise	Challenging behaviour MD -0.60 (-4.22, 3.02)	1	No significant effect of exercise on challenging behaviours.
ADL	Bahar-Fuchs (2013)	Cognitive CT	Carer reported ADL d = 0.00 (-0.38, 0.38), Z = 0.01 (p = 0.99)	4	Not associated with positive or genitive effects to any reported outcomes.
		Cognitive CR	Mean change self-reported ADL 1.22 higher	1	Potential benefits in improving ADL in people with mild AD
	Blankevoort (2010)	Exercise	d = 0.68 (0.11, 5.06)	4	BADL improved in 2 out of 4 studies. Multicomponent interventions of 45-60 min × 3/week x12 weeks or more recommended.
	Forbes (2013)	Exercise	d = 0.68 (0.08, 1.27), Z = 2.24 (p = 0.03)	6	Significant impact on ADLs but requires careful interpretation due to heterogeneity.
	Rao (2014)	Exercise	d = 0.80 (0.42, 1.19), Z = 4.07 (p = 0.0001)	6	Aerobic and strengthening exercises improve independence in ADLs.
Social interaction	Woods (2012)	Cognitive CS	d = 0.44 (0.17, 0.71), Z = 3.15 (p = 0.002)	4	Benefits on communication and social interaction.
Quality of Life	Cooper (2012)	Family carer	SES 0.24 (0.03-0.45)	4	Carer support potentially effective at improving QoL of people with dementia.
		Dyadic	SES 0.84 (0.54-1.14)	2	QoL higher in a group receiving an activity and carer strategy combined intervention.
		Cognitive	d = 0.37 (0.04, 0.71) care home d = 0.05 (-0.83, 0.93) community	1	QoL higher for care home residents.
	Leung (2015)	Social	d = 0.44	1	Support groups may be beneficial but evidence is limited.
	Potter (2011)	Exercise	Not available	2	Limited evidence on benefits on QoL.
	Woods (2012)	Cognitive CS	0.38 (0.11, 0.65), Z = 2.76 (p = 0.006)	4	Benefits on quality of life and wellbeing outcome.

AC = Active Control. ADAS-Cog = Alzheimer's Disease Assessment Scale, Cognitive Subscale. BADL = Bristol Activities of Daily Living Scale. CBT = Cognitive Behavioural Therapy. CR = Cognitive Rehabilitation. CRC = Cognitive Recreation. CS = Cognitive Stimulation. CST = Cognitive Stimulation Therapy. CT = Cognitive Training. ES = Effect Size. HLDR = Health lifestyle dementia respite. MCI = Mild Cognitive Impairment. MMSE = Mini–Mental State Examination. NAC = Non-active control group. QoL-AD = Quality of Life in Alzheimer's Disease. RO = Reality Orientation. SES = Standardised Effect Size. SMD = Standardised Mean Difference. TUG = Timed UP and GO test.

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