Complementary and supplemental non-medical therapies for dementia and cognition

Introduction

Dementia is a mental health problem that particularly affects the elderly. Alzheimer's disease and vascular dementia are both types of dementia. Damage to the brain can be caused in different ways. Blood vessel (vascular) insufficiency is one possible cause. Widespread cell death and synaptic membrane damage is detected in dementia with computed tomography (CT scans).

Brain blood vessel (vascular) insufficiency (diffuse or localised) makes itself evident with transitory ischaemic attacks, tinnitus, dizziness, headache, anxiety, memory deficiency, forgetfulness and confusion, concentration problem, tiredness, decline in capacity, a lack of motivation and depression.

Memory problems are often the first sign of dementia, typically memory for personal events and matters. Taking in new information and forming new memories becomes difficult but recalling established facts, performing skills and carrying out routines are retained in early dementia. The problems with memory can reduce self-confidence making people anxious, depressed and causing them to withdraw from activities.

As the dementia progresses intellectual and cognitive abilities such as judgement, planning and processing information decrease and emotional, motivational and personality changes develop. A person’s behaviour may become problematic and be anti-social. Wandering, verbal agitation, and general restlessness are displayed. The deterioration is distressing for the people concerned and their family and carers and often leads to a person being placed in an institution.

Alzheimer’s disease is the most common cause of dementia. It is characterised by a gradual onset and progressive decline of cognitive functions, including memory, recognition of people and things, naming familiar objects, planning and organising (executive functioning); motor function, such that a person has difficulty in carrying out everyday movements like dressing; and other features, including depression, hallucinations, behavioural agitation and aggression. Alzheimer’s disease can progress to the point where patients cannot move or talk.

Treatment of dementia involves a range of pharmacological agents (particularly cholinesterase inhibitors) and psychosocial interventions aimed at counteracting cognitive decline, and reducing the frequent accompanying problems. Given appropriate conditions and support, and sufficient time, people with dementia still have the ability to learn and retain some information and skills.

Risk factors can be genetic (a family history) or head trauma, low level of education, stress, and poor nutrition.

Cognition: the mental process of acquiring knowledge through thought, experience, and the senses.

Neuropsychiatry: relates mental disturbance to disordered brain function.

Neuropsychology: the study of the relationship between behaviour and brain function.

Recently there has been growing interest in combining medication with psychological, behavioural, supportive and other complementary therapies.

Healthcare condition	Intervention	About the findings
Cognition	Vitamin B6	2 trials
Prevention and treatment	Vitamin B12	3 trials
	Vitamin E	2 trials
	Omega-3 fatty acids	No trials
	Alpha lipoic acid	No trials
	Folic acid	8 trials
With dementia	Melatonin	3 trials
	Ginkgo biloba	35 trials
	Music therapy	3 trials
	TENS	3 trials
	Aromatherapy	2 trials
	Massage and touch	2 trials
	Homeopathy	No trials

We present some of the evidence from Cochrane systematic reviews about complementary and alternative treatments related to managing cognition problems and dementia. This evidence comes from carefully researched reviews of information about clinical trials done to evaluate medical treatments. Studies are only included in these reviews if they meet pre-defined criteria.

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Vitamin B6 for cognition

Dementia is characterised by a progressive decline in cognitive function that is severe enough to impact on a person’s everyday life. The person may have difficulties with memory, attention, language and problem solving.

Vitamin B6 is needed for body functions such as fat and carbohydrate metabolism, immune system functioning, and the formation of proteins and important brain messengers. Vitamin B6 also helps to break down homocysteine, a chemical compound in the blood which in high levels contributes to hardening of the arteries (atherosclerosis), heart disease and stroke and may also cause damage to the brain.

Adult requirements of vitamin B6 are approximately 2 mg per day and the upper tolerable limit is 100 mg. Liver, whole-grain cereals, peanuts, bananas, and (moderate amounts of) alcohol are rich sources of vitamin B6, but some older people do not have sufficient vitamin B6.

What the synthesised research says

Two small trials controlled did not find any clear effect of vitamin B6 on mood or cognitive functions for healthy older men and women.

The researchers did not find any trials involving people with cognitive impairment or dementia.

One of the trials demonstrated that taking a vitamin B6 supplement did increase blood levels of vitamin B6.

How it was tested

The researchers made a thorough search of the medical literature and found two controlled trials that randomly assigned 109 healthy older people to a vitamin B6 supplement or non-active placebo. One involved 33 women and the other included 38 men. The doses of vitamin B6 were 75 mg and 20 mg, respectively.

Cognitive performance was determined from speed of processing, short-term working memory, executive function (used for tasks like planning), and measurement of pupil size (which increases with difficult mental tasks).

Side effects and general cautions

None of the studies reported any adverse events and no participants withdrew from the trials. The duration of the trials was 5 weeks in the trial involving women and 12 weeks in the other trial. It is possible that there may be some benefit on cognition and mood if taking a vitamin B6 supplement for a longer time. Also, older people with vitamin B6 deficiency may gain more of a benefit from supplementation than those without any deficiency.

Source

Malouf R, Grimley Evans J. Vitamin B6 for cognition. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD004393. DOI: 10.1002/14651858.CD004393.

Vitamin B12 for cognition

Vitamin B12 is important in the formation of several proteins and chemicals that help to maintain the integrity of the blood cells and nervous system. Vitamin B12 also helps to break down homocysteine, a chemical compound in the blood which in high levels contributes to hardening of the arteries (atherosclerosis), heart disease and stroke, and may also cause damage to the brain. Reports have been made relating vitamin B12 deficiency with poor memory, cognitive decline and mental disturbances related to brain function abnormalities.

Vitamin B12 in the diet comes from animal sources.

What the synthesised research says

Three small controlled trials did not find any clear effect of vitamin B12 on cognitive functioning or mood. The trials involved people with dementia and low vitamin B12 levels.

One of the trials demonstrated that taking a 50 mcg daily oral vitamin B12 supplement did increase blood levels of vitamin B12.

How it was tested

The researchers made a thorough search of the medical literature and found three trials that randomly assigned a total of 182 participants to receive either vitamin B12 or a non-active placebo. The vitamin B12 was given either by mouth (a 10 mcg or 50 mcg dose) for one month in one trial or by injection of 1000 mcg for four weeks or ovwer five months.

Cognitive performance was assessed using orientation (knowing the date and where you are), immediate recall, attention and calculation, delayed memory recall, and language for example. One trial also assessed depression.

Side effects and general cautions

None of the studies reported any adverse events. Six included participants dropped out of one trial; five were in the treatment group, but the reasons for withdrawing were not specified.

The trials were small and they lasted only a short time.

Source

Malouf R, Areosa Sastre A. Vitamin B12 for cognition. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD004394. DOI: 10.1002/14651858.CD004394.

Vitamin E for cognition and Alzheimer's disease - prevention and treatment

Vitamin E is an antioxidant; that is a scavenger of oxygen free radicals which can damage proteins, DNA and cell membranes.

Sources of Vitamin E include oils and fats, nuts and other seeds, and a wide variety of animal foods but many people have a dietary intake below recommended levels. The recommended intake per day is 12 IU (8mg) for women and 15 IU (10mg) for men.

What the synthesised research says

In one controlled trial, vitamin E did not alter the time to development of possible or probable Alzheimer’s disease for people with mild cognitive impairment.

In one other controlled trial involving people already with Alzheimer’s disease, taking a supplement of vitamin E over two years had the benefit of reducing the number of participants reaching a defined endpoint that included death, admission to a nursing home, loss of two (out of three) basic activities of daily living, and severe dementia. This finding needs replication in other studies. The number of falls increased in the vitamin E group (16% compared to 5%).

How it was tested

The doses of vitamin E were 2000 IU daily and were compared to a non-active placebo. The prevention trial involved 516 participants and the trial involving people already with Alzheimer’s disease had 341 participants.

Side effects and general cautions

Vitamin E is well-tolerated and does not appear to interact with other medications. In high doses (greater than 3000 IU) it may cause gastrointestinal cramping and diarrhoea.

The included trials involved large numbers of participants and were of good quality.

Source

Isaac MGEKN,Quinn R, Tabet N. Vitamin E for Alzheimer’s disease and mild cognitive impairment. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD002854. DOI: 10.1002/14651858.CD002854.pub2.

Omega-3 fatty acids for preventing dementia

Omega 3 polyunsaturated fatty acids include long-chain and short-chain forms. The long-chain forms (including eicosapentanoic acid (EPA), docosahexanoic acid (DHA) and docosapentanoic acid (DPA)) are found in fish and other marine animals. The short-chain form (alpha linolenic acid (ALA) comes from vegetables and nuts.

Omega 3 fatty acids could reduce the risk of dementia by reducing the risk of cardiovascular disease and stroke, reducing inflammation, helping to protect the structure and function of the brain cells (as DHA is an integral component of brain cells and neurons), and omega 3 fatty acids could decrease the amount of beta-amyloid in the brain, which is involved in the development of Alzheimer’s disease.

What the synthesised research says

The researchers could not find any completed randomised controlled trials that assessed the efficacy of omega 3 fatty acids on the prevention of dementia in healthy (non-demented) older people.

Side effects and general cautions

There have been some reports of environmental contamination of fish with various toxins, such as mercury, dioxin and polychlorinated biphenyls (PCBs). A Cochrane review did not demonstrate an adverse effect of dietary or supplemental omega 3 fatty acids on total mortality, cardiovascular events, or risk of cancer.

Source

Lim WS, Gammack JK, Van Niekerk JK, Dangour AD. Omega 3 fatty acid for the prevention of dementia. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005379. DOI: 10.1002/14651858.CD005379.pub2.

Hooper L, Thompson RL, Harrison RA, Summerbell CD, Moore H, Worthington HV, Durrington PN, Ness AR, Capps NE, Davey Smith G, Riemersma RA, Ebrahim SBJ. Omega 3 fatty acids for prevention and treatment of cardiovascular disease. The Cochrane Database of Systematic Reviews 2004 2004, Issue 3 Art No: CD003177. DOI:10.1002/14651858.CD003177.pub2.Art.

Alpha lipoic acid for dementia

Alpha lipoic acid is a potent antioxidant. In theory, restoring the supply of antioxidants may reduce the oxidative stress in the brain and help to prevent or treat dementia.

What the synthesised research says

The use of alpha lipoic acid for dementia is not supported by controlled clinical trials.

How it was tested

The researchers could not find any quality randomised, double-blind, placebo-controlled trials that investigated alpha lipoic acid for dementia.

Source

Klugman A, Sauer J, Tabet N, Howard R. Alpha lipoic acid for dementia. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004244. DOI: 10.1002/14651858.CD004244.pub2

Folic acid (with or withour vitamin B12) for prevention and treatment of dementia

Alzheimer’s disease is caused by nerve degeneration in the brain and is the major cause of dementia.

Folic acid can supplement for the naturally occurring folate. Dietary sources of folate include leafy vegetables, fruits, mushrooms, yeast and animal protein. Prolonged cooking (over 15 minutes) destroys 60 to 90% of the folate content.

Folate is important in early development of the brain and maintenance of brain function and helps keep the integrity of red blood cells. It also helps to break down homocysteine, a chemical compound in the blood which in high levels contributes to hardening of the arteries (atherosclerosis), heart disease and stroke, and could also damage the brain.

Low folate levels may be caused by low dietary intake, poor absorption, or impaired metabolic use by the body. The recommended daily intake for adults is 100 micrograms and for pregnant women is 500 micrograms.

Giving folic acid to someone with a deficiency of vitamin B12 ‘masks’ the early symptoms and signs of vitamin B12 deficiency, which includes anaemia. This is dangerous as vitamin B12 deficiency can cause irreversible neurological damage. For this reason, folic acid supplements are sometimes given together with vitamin B12 supplements.

What the synthesised research says

The small number of controlled trials does not support and benefit from folic acid supplementation with or without vitamin B12 on cognitive function and mood of unselected healthy elderly people. However, in one trial involving healthy elderly people with high homocysteine levels, folic acid supplementation over three years did improve cognitive function. In a preliminary study, folic acid was associated with improvement in the response of people with Alzheimer's disease to medication (cholinesterase inhibitors).

How it was tested

The researchers made a thorough search of the medical literature and found 8 trials that randomly assigned a total of 1377 participants to receive either folic acid with or without vitamin B12 or a non-active placebo. The dose of folic acid given in the studies ranged from 0.75 to 15 mg per day, in tablet form.

The 8 trials looked at the effect of folic acid supplementation, with or without vitamin B12, on acquiring knowledge through thought, experience, and the senses (cognition). Four of these trials involved healthy older people and four included people with mild to moderate cognitive impairment or dementia.

In one trial involving healthy elderly people with high homocysteine levels, folic acid supplementation (0.8 mg) for three years was associated with significant benefits in global functioning, memory storage and the speed of processing information. No overall benefit of folic acid supplementation was seen for unselected healthy elderly people.

Three trials involved people with cognitive impairment and did not show any benefit in measures of cognitive function. Folic acid plus vitamin B12 was effective in reducing serum homocysteine concentrations.

In one trial involving 49 people with Alzheimer’s disease, folic acid supplementation (1 mg/day) clearly improved the participants’ responses to their medication (cholinesterase inhibitors). The number needed to treat (NNT) was four – this means that four people have to be treated for one to benefit from combined treatment of medication and folic acid, for six months. Daily functioning and behaviour also improved, although the amount of improvement varied markedly between individuals.

Side effects and general cautions

Only one trial reported adverse effects; only minor side effects were reported, more often in the placebo group. A review of the literature reports that folic acid has few adverse effects. The trials were mostly of short duration.

The process of gaining knowledge through thought, experience, and the senses (cognitive performance) was assessed using many measures. These included orientation (knowing the date and where you are), immediate recall, attention and calculation, delayed memory recall, and language.

Source

Malouf R, Grimley Evans J. Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004514. DOI:10.1002/14651858.CD004514.pub2.

Melatonin for cognitive impairment

Melatonin is a naturally-occurring hormone produced by the pineal gland in the centre of the brain. It helps to regulate our daily circadian rhythm (onset of sleep and sleep-wake cycle), cyclic hormone release, and the immune system; and has antioxidant properties.

It could help stabilise sleep patterns for people with dementia and its antioxidant effects in the brain might be of benefit.

What the synthesised research says

The pooled findings of three controlled trials involving people impaired processes of gaining knowledge through thought, experience, and the senses (cognition), it was found that melatonin had no effect on cognition, mood (or affect, the outward display of mood), behaviour, and functioning.

How it was tested

The researchers made a thorough search of the medical literature and found three trials that randomly assigned a total of 202 participants to receive either melatonin or placebo. Melatonin was given in tablet form at night, in a dose ranging from 2.5 to 10 mg. Outcomes were assessed using several scales designed to measure cognition, behaviour, affect and functioning.

One trial found a significant improvement in behavioural and mood symptoms in the group receiving 3 mg melatonin per day. However this trial only involved 20 participants, too small a number to make any conclusion.

Another trial reported a significant improvement in behaviour in those participants receiving 2.5 mg of melatonin per day. However this was not confirmed by a larger study with a larger dose of melatonin (10 mg per day).

Side effects and general cautions

One trial reported no adverse effects. Another trial reported mild adverse effects with both the melatonin and non-active placebo; they were more commonly reported with the lower dose of melatonin (2.5 mg compared with 10 mg). In the literature, few adverse effects have been reported in recent years. A number of older studies described worsening of depression and autoimmune conditions. The United States Food and Drug Administration states that it is “generally recognised as safe”.

Source

Jansen SL, Forbes D, Duncan V, Morgan DG. Melatonin for cognitive impairment. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD003802. DOI: 10.1002/14651858.CD003802.pub3.

Ginkgo biloba and cognitive impairment

The leaves of the maidenhair tree, Ginkgo biloba, have been used for a long time as a traditional medicine in China. The trees are separate, male or female, and are believed to be the oldest living tree species. They are extremely robust in resisting insect and fungus attack amd surviving frosts; a tree can survive for 1000 years. Large commercial plantations are now grown in many parts of the world.

Ginkgo biloba was introduced into Germany in 1965 and was prescribed extensively as a standardized extract for cerebral insufficiency, age-related cognitive decline and dementia. It may have an antidepressant effect.

Ginkgo biloba is available in many parts of the world, including UK, Canada and the USA, as a food supplement.

What the synthesised research says

Recent trials do not confirm the benefit suggested by several older, small controlled studies that found Ginkgo to have benefits for people with dementia or cognitive impairment.

How it was tested

The researchers identified 35 randomised controlled studies involving 4247 people with dementia or age-related cognitive impairment. The duration of the studies varied from 3 weeks to one year, with the majority lasting some 12 weeks. The daily dose of Ginkgo ranged from 80 to 600 mg/day of a standard extract, usually less than 200 mg/day and was compared with a non-active placebo.

Taking Ginkgo (in a dose less than 200 mg/day) resulted in no overall clinical improvement as assessed by the physician.

Ginkgo (in any dose) showed some benefits on cognition when measured at 12 weeks (5 studies) but not at 24 weeks.
Looking at activities of daily living (7 studies), Ginkgo (dose less than 200 mg/day) showed improvements (measured on a number of different scales) after 12 and 24 weeks of treatment but there were no differences at the higher dose.

In two trials, Ginkgo (in a dose greater than 200 mg/day) over 24 weeks benefitted more participants than did the placebo but the lower dose did not.

Two studies reported benefits associated with Ginkgo (dose less than 200 mg/day) on global function at up to 12 weeks of treatment.
No information was available on quality of life or measures of depression.

Side effects and general cautions

Overall, the numbers of people who dropped out from treatment before the scheduled completion date or who experienced adverse events were similar with Ginkgo and the placebo. Most of the studies only included participants who completed the treatment in their analyses.

Many of the early trials used unsatisfactory design methods, the trials were small, and used many different tests to assess outcomes; this meant they were not assessing the same aspects of cognition. Although there were 35 included studies, only 29 contributed data to the meta-analyses and of these 15 studies contributed very little.

Many of the trials received funding from Dr Willmar Schwabe GmbH & Co, the company that manufactures the most widely used standardised extract of Ginkgo biloba. There may initially have been a bias toward only publishing trials with positive results.

Source

Birks J, Grimley Evans J. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003120. DOI: 10.1002/14651858.CD003120.pub2.

Music therapy for people with dementia

Helping people with dementia and their carers cope with associated problematic behaviours such as general restlessness, wandering, verbal agitation, and anti-social behaviours, is an important part of care. Many care approaches depend on verbal communication so that when language is no longer possible, other ways of communication are needed. People with dementia may still be able to sing a song even when they are incapable of ordinary speech and music therapy could help in their care.

The World Federation of Music Therapy defines therapy as the use of music, sound, rhythm, melody and harmony by a qualified music therapist to promote communication, relationships, learning, mobilisation, expression, organisation and other relevant therapeutic objectives for a client or group.

In dementia the specific goals include stimulation of social interaction, reduction of agitation and helping to cope with emotional problems. A music therapist uses listening and activities such as playing on small instruments, dancing, movement, or singing.

What the synthesised research says

Behavioural issues

Three controlled studies found that music therapy reduced behavioural problems. The specific situations were different: during bathtime, at the time of days when the participants were most agitated, and to reduce wandering during sessions. Music listening was effective.

Verbal communication and participation

For one study, music therapy more effectively improved speech content and fluency language skills than conversation sessions where pictures and photographs were used to stimulate discussion and reminiscence.

In another study, people were happier, more alert and had higher recall of past personal history after music therapy where they listened to ‘Big Band’ music and were given children's musical instruments so that they could actively participate than those in the control groups (wooden jigsaw and other puzzle activities and general activities of drawing, painting and watching television).

How it was tested

The review authors identified five randomised controlled studies from the literature.

Behavioural issues

Three studies compared music therapy with a control intervention to reduce behavioural problems.

Playing people's preferred music (compared to no music) during bath time decreased aggressive behaviours (hitting, biting, screaming, crying, abusive language, wandering, spitting, refusal to cooperate, pinching, scratching and throwing objects). This study involved 18 people receiving each treatment for 2 weeks (10 bathing sessions).

Playing people’s preferred music (compared with classical relaxation music) reduced agitated behaviours immediately and 30 minutes after listening to the music. This study involved 39 elderly people with dementia who received each treatment for 6 weeks.

Using music (rather than reading) increased the amount of time a wandering demented elderly person remained seated or in close proximity to the session area. Reading sessions consisted of reading aloud to the participant and sometimes being read aloud to by them. The 30 participants received seven one-to-one sessions of 15 minutes maximum per day for seven days (either five music and two reading sessions, or five reading and two music sessions) and were assessed before and after each session.

Verbal communication and participation

The study investigating whether music therapy improved language functioning cognitive skills involved 26 residents of a nursing home for people with Alzheimer's disease and related disorders. The residents participated in small groups twice a week for a total of eight sessions, receiving both treatments by being crossed over to the other therapy after four sessions.
The fifth study involved 60 people randomly assigned to a group who were played six 30-minute sessions of music therapy; a group given puzzles, or a third group with no special activities.

Side effects and general cautions

The methodological quality of the studies and reporting were generally poor and each study was very different. The intervention periods were less than four months.

Source

AC Vink, JS Birks, MS Bruinsma, RJPM Scholten. Music therapy for people with dementia. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003477.pub2. DOI:10.1002/14651858.CD003477.pub2.

TENS for dementia

TENS (transcutaneous electrical nerve stimulation) generally uses electrical pulses alternating between positive and negative polarity. The intensity and duration of the pulses are carefully adjusted to produce either a comfortable tingling sensation without pain or muscle contraction or tingling with a muscle contraction. TENS is most commonly used to manage pain. Its possible use in dementia is based on the concept ‘use it or lose it’ related to brain activity.

Electrodes are commonly made of fabric or thin plastic coated on one side with a self-adhesive conductive gel so that they stick to the person’s skin in the area where the stimulation is to be given. The stimulator generally uses batteries and is about the size of a pager. Electrodes are placed on the earlobes or the head to produce cranial electrical stimulation (CES) for improving sleep-wake patterns and other behaviours in people with dementia.

What the synthesised research says

A number of controlled studies carried out by a group in the Netherlands and a study from Japan report that applying TENS to the middle of the back or to the head can improve the cognition tasks such as word recall and face recognition, motivation, and behaviour for people with Alzheimer's disease or multi-infarct dementia. These were isolated positive findings amongst a large number of neuropsychological and behavioural tests.

How it was tested

The review authors included 9 randomised controlled trials but only 3 trials had sufficient data for pooling results (meta-analysis). The control groups had the TENS in place but no current was delivered.

Applying TENS to the mid back near the spine improved both delayed recall of 8 words (one trial) and face recognition (two trials) measured immediately after 6 weeks of treatment. TENS also increased motivation after 2 weeks of application to the head (one study from Japan).

Other related mental and behavioural measures did not show any clear effects when evaluated either immediately or 6 weeks after completion of 6 weeks of treatment with TENS. Sleep disorder, motivation, behaviour, intelligence, emotion, language, neurological signs, subjective complaints and activities of daily life.were all evaluated.

The Dutch studies each involved 8 to 20 participants from a group of 350 to 500 residents of a residential home for elderly people. The participants were mainly female with early or midstage Alzheimer’s disease. All but the most recent study used TENS at a strength that was sufficient to produce visible muscle twitches applied to the back. The most recent study used cranial electrostimulation with the electrodes on the earlobes.

The group in Japan involved 27 people with multi-infarct dementia or Alzheimer's disease who had irregular sleep-wake patterns and night time behaviour disorders or delirium. Transcranial TENS was given with electrodes attached to the forehead and (lower) back of the head using a headband.

Although these findings suggest that TENS may improve some neuropsychological aspects of dementia, they should be interpreted with caution because they are or 6 weeks after treatment was completed.

Side effects and general cautions

Most studies did not document that they looked for adverse effects. The only adverse effect mentioned was in one study where one patient complained of a dull pain the head with cranial electrical stimulation.

TENS is unlikely to have significant risks. Some people have poor tolerance to the sensation of electrical stimulation and others react to the adhesive with an allergic rash; fragile, thin skin may be damaged by removal of self adhering electrodes.

TENS could possibly alter heart rhythm if people have demand heart pacemakers, or worsen epileptic activity.

Most of the currently published studies are well designed, although the numbers of participants in each study was small.

Source

M Cameron, E Lonergan, H Lee. Transcutaneous Electrical Nerve Stimulation (TENS) for dementia. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD004032. DOI:10.1002/14651858.CD004032.

Aromatherapy for dementia

Verbal interaction may be difficult for people with advanced dementia and conventional medicine of only marginal benefit

Aromatherapy is a complementary therapy using pure essential oils from fragrant plants to help relieve health problems and improve wellbeing. Applying the oils may calm disturbed behaviour, promote relaxation and sleep, and stimulate motivational behaviour.

Oils include lavender, Roman chamomile, mandarin, geranium, rose, peppermint, sweet marjoram, sweet orange, melissa, patchouli, tea tree and vetiver and are easily accessible from pharmacies and health product stores. They are most commonly used in oil burners, in bath water, or massaged into the skin so that the aroma of the essential oil evaporates and stimulates the sense of smell.

Some people are trained as aromatherapists.

What the synthesised research says

Aromatherapy over 4 weeks showed benefit for people with dementia on measures of agitation and mental and functional disorders related to the changed brain function in the only controlled trial that contributed data to this review.

How it was tested

The researchers identified two controlled trials with a total of 93 patients.

The trial with usable data randomly assigned 72 people with severe dementia and significant agitation to Melissa or sunflower oil applied topically to the arms and face twice daily for 4 weeks according to the specialist nursing home they were in. Most of these people were on medication to control their behaviour and the medication could be changed during the trial, if necessary.

It was not possible to use the results from one of these trials, which involved lavender applied with massage, lavender in a diffuser accompanied by conversation, or massage only. The 21 dementia patients were observed by video camera in a district general hospital ward. Although there was no difference between groups the investigators found that the effect of massage with aromatherapy depended on the time of day, with the greatest improvement in specified behaviours, relative to the other conditions, between 15.00 and 16.00 hours.

Side effects and general cautions

Aromatherapy may cause some adverse effects.

Randomising centres and not individual participants meant that only one substance was used in each facility but the 8 nursing homes could have other differences that also affect the findings.

The effects of the aromatherapy may vary for different types of dementia and if the aromatherapy oil is changed.

Source

L Thorgrimsen, A Spector, A Wiles, M Orrell. Aroma therapy for dementia. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003150. DOI:10.1002/14651858.CD003150.

Massage and touch for dementia

People with dementia often express anxiety, emotional distress, agitated behaviour, and depression.

Massage and touch are used in professional care with to counteract cognitive decline and reduce depression, anxiety, aggression and abnormal behaviours. The sensation of touch or being near has an immediate calming, reassuring influence and is a matter of course in a family or home environment. Touch and massage may also be seen as a way to 'stay in touch' and retain a sense of meaningful, reassuring communication even when words begin to fail a person with dementia. The sensory stimulation involved may stir memories and provide meaningful cognitive stimulation.

The back, shoulders and neck; the hands, arms and shoulders; only the hands; or only the lower legs and feet can be massaged using: tender touch with large strokes, slow strokes, expressive touch, rubbing, kneading, or circular stroking with the palm of the hand (effleurage). Encouragement and friendly words may be communicated. In other cases the caregiver's calm state is important and with therapeutic touch the therapist's hands are held near the patient's body but not in physical contact. Reflexology, shiatsu and acupressure are other possible methodss.

Nursing staff, therapists, investigators and research assistants, or family members may provide the touch or massage.

What the synthesised research says

The very limited amount of reliable evidence that is available favours massage and touch for problems associated with dementia in two very specific situations: hand massage reduced agitated behaviour, immediately and in the short term; and the addition of touch to verbal encouragement to eat improved nutritional intake. The behavioural and mood problems associated with dementia make people confused and disoriented so that they often wander from the table and leave their food.

How it was tested

The review authors identified two controlled studies with a total of 110 participants that could be included in this review.

One study randomly assigned 68 nursing home residents to receive a single treatment (hand massage, calming music or both) or no treatment. It reported a decrease in agitated behaviour that was greater in the group receiving a single 10 minute treatment with hand massage. The benefit continued for one hour after treatment. The treatment effects were comparable to the effecs of other treatments, both pharmacological as well as non-pharmacological.

The second study randomly assigned 42 institutionalised patients with ‘chronic organic brain syndrome’ to verbal encouragement to eat combined with touch or verbal encouragement alone. Over one week the mean intake of calories and protein increased when touch was added (from 570 to 740 cal/day and 32 to 43 g/day, respectively).

Side effects and general cautions

Sometimes a person may find the massage or touch uncomfortable. The trials appeared methodologically sound but were very small. Both of the included studies only assessed immediate and short-term effects on behaviour. The scope of the two trials is too limited to allow general conclusions.

Source

N Viggo Hansen, T Jørgensen, L Ørtenblad. Massage and touch for dementia. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004989.pub2. DOI:10.1002/14651858.CD004989.pub2.

Homeopathy for dementia

Homeopathy was developed by the German physician Samuel Hahnemann in 1796. He noted that quinine was effective in the treatment of malaria yet in large doses caused symptoms similar to malaria and proposed the principle "let like be cured by like" (similia similibus curentur). The starting point of a homeopathic remedy is the 'mother tincture'. This is produced by letting the specified ingredient stand in an ethanol and water mixture for several weeks. The mother tincture is then serially diluted with vigorous shaking (succussion) at each stage. This process is sometimes called 'potentisation'. The final liquid dilution is usually absorbed on to pills made of lactose or sucrose for use. It has been diluted so many times that it is unlikely to contain any of the original molecules from the mother tincture. Such dilutions are known as 'ultra molecular'. Homeopathy is a popular form of complementary or alternative treatment.

What the synthesised research says

The researchers could not find any randomized controlled studies evaluating the effectiveness and safety of homeopathically prepared medications for people with dementia involving at least 20 people.

Side effects and general cautions

The extent of homeopathic prescribing for people with dementia is not clear.

The report of the one excluded trial did not note any adverse events related to the trial medication.

Source

R McCarney, J Warner, P Fisher, R Van Haselen. Homeopathy for dementia. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003803. DOI:10.1002/14651858.CD003803.

This review was last assessed as up-to-date in March 2009; no new trials were found.

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