The Benefits of therapies activities such as reality orientation

This paper will consider the effectiveness of psychological activities, such as reality orientation therapy, in the treatment and support of patients with dementia.  Dementia is a progressive and debilitating neurological disorder associated with a decline in cognitive functioning, impaired memory, change in personality, self neglect, depression, confusion in thought, language and behaviour, including disorientation.  Psychiatric aspects of the disorder that maybe treated through psychological therapies include depression/ anxiety symptoms, behavioural and personality disturbances and hallucinations/ delusions (Kasl-Godfrey and Gatz, 2000).

However, although the functional and cognitive impairments associated with progressive dementia are well understood, less is known about the subjective experience of living with dementia from the perspective of the patient and their care-giver(s). The lack of knowledge may lead to avoidable affective aspects of the disorder being undiagnosed, and the patients existing personal abilities and psychological potential underutilised, and coping methods not fully explored (Kasl-Godley and Gatz, 2000). 

It is more likely in the elderly and in the United Kingdom an estimated 600,000 people have dementia. This represents 5% of all persons over the age of 65, and 20% of all persons over the age of 80 (Bates, Boote and Beverley, 2004). As life expectancy increases in the population, it is predicted that the number of people that will develop dementia will also rise to 1.2 million by the year 2050 (Department of Health, 2001). In the absence of effective pharmacological treatments for dementia, it is necessary to consider the role of psychotherapeutic interventions in remediating the difficult and distressing symptoms of dementia amongst patients. At present, pharmacological treatments would only appear to be effective in delaying the onset of severe Alzheimer’s disease and there are individual differences in patient response to treatment.  Furthermore, pharmacological treatment is not tolerated by some patients because of the side effects such as nausea and vomiting.  In view of the limitations of pharmacological treatment, it is necessary to consider the effectiveness of psychological therapies such as the reality orientation method.  At present, little is understood about the ‘critical windows’ for introducing psychological therapies to dementia patients so that “treatment strategies stand a better chance of success” (Bates et al, 2004, p 645). 

Psychotherapeutic approaches to dementia care are ethical, in that they promote user participation, holistic ‘whole person’ care and place the needs of the patient as the first priority (Bates et al, 2004).  Particular interest in psychotherapeutic measures rests with the desire to overcome the temporal and spatial disorientation aspects of dementia that can be most distressing to patients (Baldelli et al, 2002). Furthermore, there is strong policy driven support for the provision of such therapies to older people with dementia.  In the National Service Framework for Older People, it is recommended to use “non-pharmacological management strategies such as mental exercise, physical therapy, dietary treatment alongside drug therapy. These may be beneficial in reducing the impact or slowing down the progression of the disease” (Department of Health, 2001, section 7.39).  However, it is necessary to carefully evaluate the respective therapies that are proposed to be beneficial in the treatment of dementia. Some systematic reviews have attempted to evaluate the efficacy of psychotherapeutic intervention with dementia patients, but have failed to differentiate between the different stages of dementia (for example, Koger and Brotons, 2002). This is unfortunate, since stage of dementia is likely to be vital to the patient’s responsiveness to psychotherapeutic intervention and is an important consideration in planning health care services. 

Therefore, a systematic review was undertaken by Bates et al (2004) that assessed if psychosocial interventions are effective for people with mild to moderate dementia.  Two of the studies reviewed by Bates et al (2004) were appraising reality orientation therapy (ROT).  The ROT intervention is used with confused patients with dementia who are experiencing disorientation as to time, place and persons in their environment. There are variations in how it is delivered but a typical model is proposed by Savorani et al (2004) of formal classroom instruction to familiarise the care-giver and patient with the method, and then a period of continuous exposure to the method in the natural setting of the patients home or hospital environment.  The considerable interest in ROT is based on its person centred methods that are respectful of others, and value the patient with dementia and provide opportunities for reminiscence, validation of experience and improve sensory-motor stimulation to promote patient communication and quality of life (Savorani et al, 2004). The aim of ROT is “to recruit functions such as attention to facilitate retrieval or temporal and spatial references and personal and interpersonal traces from mneumonic stores.  ROT exploits clear and repeated references to time, space, and persons integrated in the patient’s habitat to provide a fixed reference points and retrain orientation in confused objects” (Baldelli et al, 2002, p 16).  The ROT philosophy is that dementia related confusion occurs when the patient is understimulated, there is a lack of insistence that normal behaviours are achieved by the patient, and when desired behaviours are achieved by the patient they are not reinforced positively by care-givers.  Mental stimulation is assumed to improve clarity of mind by activating dormant neural pathways in the brain and requiring patients to use appropriate behaviour, and function independently. Furthermore, social engagement provides a stimulating environment and raises expectations and providing new ways of functioning that compensate for lost behaviours or lifestyles (Kasl-Godley and Gatz, 2000). 

Both studies from the systematic review by Bates et al (2004) included the MMSE and Geriatric Depression Scale (GDS) as outcome measures, but there were differences in the time frame, rate of attrition, how reality orientation therapy was delivered and sample size between studies.  Baseline MMSE scores for the dementia patients were similar, suggesting that there were clinically approximate populations in terms of cognitive functioning.  In the study by Zanetti and colleagues, a statistically significant difference in cognitive ability, as measured by the MMSE scores, between the treatment group and control group was observed. However, no statistically significant differences were recorded in communication, cognitive ability measured through a memory task, functional performance and well-being of the patients. In a second study by Baldelli and colleagues, a significant improvement was found in the treatment group in terms of cognitive ability and functional performance but there was no statistically significant differences in both groups.  In this study, follow up data were obtained from patients three months after the intervention stopped and it showed that treatment effects were enduring. As Bates et al (2004) suggest, “there is evidence that reality orientation is an effective intervention in improving cognitive ability, as measured using the MMSE…Neither study demonstrated that reality orientation is effective in improving well-being, as measured by the GDS.  Finally, no evidence as found that reality orientation is effective in improving communication, functional performance and cognitive ability measured in terms of memory recall” (p 651). One study by Zanetti and colleagues (1997) was reviewed that evaluated the procedural memory stimulation method.  This compared 10 dementia patients, to 10 adult controls.  Cognitive ability and functional performance was recorded before and after the intervention for each participant, but no statistically significant improvement was found after treatment. The researchers had concluded that the treatment had not been beneficial on the patients, but they failed to consider that their low sample size may have affected their ability to achieve a statistically significant result. A further study by LaBarge and colleagues was included in the systematic review that was a standard counselling intervention on dementia patients.  There were 19 research participants and 8 of these had diagnosed mild dementia. The intervention comprised of two 50 minute counselling sessions, but the first session was used for assessment and test taking activities. The second session provided an opportunity for patients to ‘ventilate’ their concerns about their illness and receive information from professionals.  The well-being of participants was assessed using a self concept scale and a personality inventory, and there was no impact of counselling on the patients.  No statistically significant effects were observed for the counselling intervention in this study.

Savorani, Chattat, Capelli, Vaienti et al (2004) published a research study that examined the clinical effectiveness of the reality orientation method on 34 dementia patients at a day hospital.  A battery of standardised assessments were obtained from the patients on one or more occasions to assess cognitive and emotional functioning.  Classroom based instruction was carried out every day for four weeks and covered memory, orientation tasks and attention span activities.  A coursebook including the programme steps was given to the care-giver so that the ROT method could be used at home with patients, but repeated testing was only achieved for five patients at the end of the study. Nevertheless, the researchers recorded a comprehensive improvement in the cognitive functioning, language and memory of the patients as well as emotional functioning amongst the five patients.  In another study of reality orientation therapy, Baldelli, Boiadri, Fabbo, Pradelli and Neri (2002) reported that patients receive ROT treatment scored better on cognitive tests at the end of the intervention, compared to a control group of patients with dementia that received standard physical therapy alone.  However, the researchers observed that patients receiving physical therapy also improved as a result of intervention, but not as much as the ROT group.  All the patients were assessed on the MMSE, but measures of daily activity and affective functioning were also obtained.  For both groups, significant differences were observed after treatment in depression scores and daily activity, but only the ROT group was associated with a significant improvement in the MSSE score.  In their view, ROT has wide ranging consequences for the dementia patient; “ROT effects may not be limited to improving orientation, but also interact in a complex way to improve skills in goal-orientated ADL [affective functioning], thus promoting autonomy” (p 20).

A systematic review of the effects of ROT on patients with dementia was undertaken by Spector and colleagues for the Cochrane Collaboration project.  Six trials of ROT were included in the systematic review, and the results show that treatment had a statistically significant effect on cognition and emotional aspects of dementia.  There were no reported side-effects or adverse outcomes of patients being involved in ROT interventions.  However, this systematic review was confined to classroom methods of delivering ROT and did not consider the long term benefits of treatment due to lack of available studies.  In further work by the same team, Spector, Thorgrimsen, Woods, Royan et al (2003) have also considered the clinical effectiveness of ROT with dementia patients in a clinical trial. They conducted a randomised, controlled trial in London, with 115 patients that had dementia and attending NHS day centres.  This is the only randomised controlled trial of its kind in the world, and informed the Cochrane Collaboration on Evidence Based medicine. Each patient was assessed prior to the intervention on a battery of measures including cognitive functioning (MMSE), communication, behaviour, depression, anxiety and a Quality of Life test.  Control group participants received usual care at the day centres, while the treatment group received cognitive stimulation therapy (ROT) over 14 sessions across 7 weeks.  The intervention was designed around the theoretical concepts of reality orientation and cognitive stimulation.  Of the 115 patients, 97 were assessed at follow up and 70 of the control group.  The mean attendance to treatment sessions was 11.6 suggesting high compliance amongst the group.  At follow up, the treatment group demonstrated significantly higher scores on the MMSE and quality of life measures.  There was also a trend towards improved communication for the treatment group. However, no difference was found between the groups in terms of functional ability anxiety or depression. There were also gender differences in final test score results. Quality of life scores improved more for women in the treatment group than for men, whereas in the control group the quality of life of men had deteriorated more than for women. As this is the best quality trial that has been undertaken in the field of ROT, it is interesting to note that improvements were observed in the cognitive functioning of treatment group participants. 

Woods (2004) has argued that there is no “quick fix” to dementia, but novel psychotherapies offer a useful alternative to drug based interventions.  Furthermore, Woods (2004) argues that psychotherapies must target the specific symptoms of dementia such as anxiety and depression, but in order to help the patient there needs to be a re-conceptualisation of the role of therapy, and an acknowledgement of the social construction of mental illness. He argues, “In general, clinical psychologists prefer (although they are not completely happy about this) to talk of behaviour that challenges, because it is an implicit reminder that the problem lies in part with our reaction to the behaviour, which of itself may not present a problem to the person with dementia. Challenging behaviour is a function of a particular care environment, in a different care setting, the behaviour in question may not be elicited, or may not be viewed as a problem by those providing care” (p 180).  Therefore, the use of psychosocial interventions with patients must acknowledge the purpose of therapy and be individualised to the needs of the patient (Woods, 2004).  A further review of psychotherapeutic interventions with dementia patients has been published by Kasl-Godley and Gatz (2000).  Based on research evidence from interviews with dementia patients, it is argued that “the symptoms and behaviours of demented individuals are not solely a manifestation of the underlying disease process, but also reflect social and environmental context, as well as the demented individual’s perceptions and reactions” (p 757).  As a result, psychotherapies should, “reflect a theoretical view for understanding the person and psychological health prior to dementia, (2) build on knowledge of the psychological impact of dementia, including how cognitive changes caused by dementia contribute to distress, (3) apply strategies that alleviate distress, facilitate coping, support personal resources and maximise functioning and (4) have empirical evidence for the intervention when used with individuals with dementia” (p 757).  Kasl-Godley and Gatz (2000) have reviewed studies of reality orientation therapy with dementia patients.  They note that the vast majority of studies of ROT have focussed on the outcomes from classroom based intervention, and the overall outcome of most studies has been that dementia patients exhibit improvements in cognitive functioning, largely in the area of orientation and attention.  However, there is little evidence of improvements in behavioural measures in available studies.  Furthermore, long term gains from treatment appear to be small.  Kasl-Godely (2000) raise concerns about the quality of the research evidence in this field; “A number of design issues with the research have been noted such as the procedure of using training material in the evaluation of the technique; and the variability in administration of intervention techniques, which is especially problematic when other potentially therapeutic components are introduced such as increasing the number of activities available to residents.  Non-specific treatment effects (e.g. increased communication with staff, involvement in social activity, attention to appropriate behaviour) apparently do help to explain treatment outcomes” (p 769).

Although research has focussed on the effects of psychosocial treatment on the patient with dementia, few studies have considered its impact on the care-giver and relatives. This is unfortunate, since care-givers are vital for maintaining community care for patients with dementia, and “Successful caregiver interventions have been demonstrated to reduce caregiver distress, depression, and psychological morbidity; to delay nursing home admission of patients; and to improve patients’ psychological well-being” (Brodaty, 2004, p 144). Indeed, involving care-givers in the delivery of psychosocial interventions maybe empowering and do something to alleviate feelings of helplessness in dealing with an incurable disease. Furthermore, psychosocial interventions delivered by caregivers may promote a better quality of interaction with the patient.  Brodaty (2004) conducted a study with 24 patients with early dementia, along with their care-givers, to evaluate the “Making Memories” intervention programme.  It was hypothesised that participation in the treatment programme would lead to lower caregiver distress, depression, reaction to problem behaviours and also lower patient distress. The intervention comprised on patients attending memory loss groups and the caregivers attended separate groups where they could discuss their experience of caring for a dementia patient and planning for the future.  Baseline, after-treatment and 6 month follow-up measures were obtained from each patient and care-giver. It was observed that there was a statistically significant decrease in the care-givers reaction to problem behaviours scores at the end of the intervention, but increasing by the 6 months follow-up.  However, there were no significant differences in caregiver depression or psychological morbidity scores.  The general health scores from the dementia patients declined steadily over time suggesting that there was no apparent benefit of treatment to them personally. 

Research studies considering the impact of psychotherapeutic interventions on dementia patients have been hindered by poor methodologies.  Bates et al (2004) highlight the difficulty in conducting systematic reviews in this area, because there are no standard definitions of stages of dementia.  In the absence of a standardised measure, it is unclear if the populations of dementia patients in individual studies are at the same clinical stage of the disease.  This presents a challenge for considering the effectiveness of psychotherapies and deciphering the best times in the dementia patients treatment programme to commence psychotherapies. 

The standards of research methodology applied in dementia studies is generally poor. In the Bates et al (2004) systematic review, they identified 208 published papers related to psychological interventions for the treatment of dementia, but only 4 of the research studies were of sufficient standard to warrant inclusion in their report.  Bates et al (2004) complained that their “systematic review has revealed a paucity of well-designed studies focusing on the effectiveness of psychosocial interventions for people with a milder dementing illness” (p 653). A particular difficulty is the lack of a control group in many of the studies.  While control groups are necessary to eliminate placebo effects in trials, this can be particularly problematic in the sensitive area of dementia care.  As Finnema et al (1998) has argued, “One of the ethical problems is that one withholds the expected beneficial approach from the control group” (p 194).  Finnema, Dores, Van Der Kooij et al (1998) have described their research proposal for conducting a large scale study on the effect of emotion-orientated care delivered by 120 nurses to 391 patients with dementia in hospital wards. A range of standardised measures were taken from patients at the start of the study, and repeated at the end to measure cognitive and emotional functioning, depression, agitation and activity levels.  They suggest that standardised measures need to be combined with qualitative interview and observational data to obtain any understanding of the role of psychosocial intervention in dementia care. Furthermore, the possibility of Hawthorne effects, along with other non-specific treatment effects must be considered. As Bates et al (2004) argue, it is impossible to blind patients and practitioners to the intervention arm of any trial, and this may include a performance bias.  Furthermore, sample sizes in trials tend to be small and few report effect sizes for treatment. The small sample sizes can have implications for statistical power since potentially useful therapies maybe abandoned due to the lack of a statistically significant result, which maybe due to insufficient statistical power as opposed to the actual effects of treatment. Indeed, Bates et al (2004) comment that “little can be concluded about the effectiveness of procedural memory stimulation and counselling on the findings of these two studies alone, because the sample sizes were small, and no consideration was given to statistical power” (p 653). Furthermore, attrition bias can be a particular challenge of psychotherapeutic trials with dementia patients.  Non-compliance or withdrawal from group work by individual patients can have important implications for other group members. “A major practical problem one encounters is the loss of subjects due to the death or transfer of residents to other wards during the research period.  Anticipating this problem in a one year experiment, one has to start the study with a sample being e.g. 40% larger than normally required to obtain a sufficient statistical power to detect a medium to large effect size” (Finnema, 1998, p 194).

Bates et al (2004) recommend that better quality research is required before the effectiveness of psychosocial therapies with dementia patients can be ascertained.  In particular, they state “sample sizes tended to be small, with a reliance on convenience sampling, so that the likelihood of all four included studies being sufficiently powered is open to question.  Secondly, random allocation to study groups was not mentioned in three of the included studies in which it was appropriate to do so….Thirdly, blinding to the measurement of outcomes was only described in two of the studies. Finally only one study included the collection of follow-up data, to examine the longer term impact of the intervention” (p 654). Convenience sampling at single clinic sites may include patients at different stages of the disease, and this has important implications for interpretation of research findings. Therefore, multi-centred randomised controlled trials are required to assess the clinical effectiveness of respective treatments. 

In conclusion, it is apparent that psychosocial therapies such as the reality orientation method have a potentially important role in maintaining quality of life amongst dementia patients. Indeed, the use of psychosocial therapies is encouraged by national health policy on the treatment of dementia patients.  There is considerable research evidence on the effectiveness of psychotherapies for dementia patients but it is generally poor quality, and not useful when making clinical judgements about the provision of psychological support as part of the treatment and care package offered to individual patients. While there is a general sense that some therapies such as reality orientation are beneficial to cognitive functioning, little is understood about the individual differences in how patients respond to treatments. Furthermore, little is understood of the effectiveness when combining pharmacological and psychotherapeutic interventions in the patient’s treatment programme, or what patients themselves think about the psychotherapies they are involved in.  


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