Editorials

Sensory stimulation in dementia

An effective option for managing behavioural problems

Most older people with dementia at some point in their illness develop psychiatric symptoms or behavioural disturbances such as agitation, aggression, depression, delusions, wandering, sleep disturbance, and hallucinations. Collectively, these are termed behavioural and psychological symptoms of dementia.¹ They are frightening for patients and their carers; constitute a major management problem for psychiatrists, general practitioners, and geriatricians; and act as a trigger for admission to institutional care. After excluding treatable causes such as concurrent infections, non-pharmacological approaches such as behavioural management are the recommended first line intervention.²

In practice, however, drugs such as neuroleptics and other sedatives are often prescribed in an attempt to control what can be an alarming situation. Although neuroleptics have modest term efficacy in the short term,³ they are associated with side effects such as sedation, extrapyramidal signs, falls, a detrimental impact on quality of life,⁴ and, possibly, accelerated cognitive decline.⁵ These side effects are most pronounced in people with severe dementia, exactly the group who have most behavioural and psychological symptoms and for whom no evidence is available from placebo controlled trials of neuroleptics or other psychotropic agents. A wide range of alternative approaches has been tried, including multisensory interventions such as snoozelan (involving fibreoptic lights and touch) but reports have essentially been qualitative and based on small numbers of patients. Two exceptions are aromatherapy and bright light treatment, which have emerged as promising treatments.

Aromatherapy has a long history and is the fastest growing of all complementary treatments. Three placebo controlled trials have been completed in the last year, and each has reported a significant beneficial effect on agitation compared with placebo, with almost complete compliance and no side effects (table). In addition, as opposed to neuroleptics, which seem to be associated with a detrimental impact on wellbeing, quality of life significantly improved with aromatherapy.⁸

Lemon balm (Melissa officinalis) or lavender oil (Lavendula officinalis) are the two main agents used and are delivered by either inhalation or skin application.^6-8 Almost all participants in the studies completed the course of treatment. This emphasises the excellent tolerability of aromatherapy, which is in contrast to many of the pharmacological treatments in this group of patientsit is common for 30% or more of the participants to be unable to complete a trial. Explanations for the efficacy of aromatherapy range from subjective psychological to direct biological action. In the studies cited no extended period of massage was used, and a direct chemical effect seems therefore likely. ^{6 8} Essential oils contain many terpenes, which are rapidly absorbed through the lungs and cross the blood-brain barrier. In addition, many possess cholinergic activity or act on  aminobutyric acid receptors. ^{12 13}

Bright light is effective in the treatment of seasonal affective disorder.¹⁴ The technique involves sitting in front of a light box with the entire visual angle subtended by the light sourcethe amount of light is important (up to 10 000 lux compared with average office light, which is up to 300 lux). Three controlled trials have been published in the past three years that investigate the effect of bright light on sleep disturbance and behavioural disorders in dementia (table).^9-11 Some benefits were reported for restlessness, but a particular beneficial effect has been found for sleep disturbances. These results are promising.

People with dementia are among the most vulnerable in our society. Symptoms often need to be treated expediently, and drugs, although moderately effective, can be hazardous. Aromatherapy and bright light treatment seem to be safe and effective and may have an important role in managing behavioural problems in people with dementia.

Alistair Burns, professor of old age psychiatry. 
Jane Byrne, senior lecturer in old age psychiatry. 

University of Manchester Department of Psychiatry, Education and Research Centre, Wythenshawe Hospital, Wythenshawe, Manchester M23 9LT

Clive Ballard, professor of old age psychiatry. 

(c.g.ballard{at}newcastle.ac.uk), Wolfson Research Centre, Institute for Ageing and Health, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE

Clive Holmes, senior lecturer in old age psychiatry. 

Thornhill Research Unit, Moorgreen Hospital, West End, Southampton SO30 3JB

Footnotes

Competing interests: AB, CB, and JB have received honorariums, consultancy fees, and research grants from Janssen and Astra Zeneca, both of which manufacture products that are used in the management of behavioural disturbances in people with dementia. AB is editor of the International Journal of Geriatric Psychiatry, which publishes peer reviewed academic papers in old age psychiatry and occasionally publishes supplements sponsored by pharmaceutical companies.