AGITATION, aggression and sleep disturbances are commonly associated with dementia, and heavy-duty sedatives often used to curb these symptoms do so simply by reducing the patient to the state of a zombie. But new research suggests that there are effective and gentler alternatives to the “chemical cosh”.
According to a report just published in the British Medical Journal (BMJ), aromatherapy (massage or inhalation with strongly scented essential plant oils) improves disturbed behaviour among people with dementia. The research also showed that light therapy — whereby the patients sit near a special light source for 30 to 60 minutes a day — reduced the nocturnal wakefulness associated with the condition.
Most people with dementia at some point develop behavioural and psychological symptoms such as agitation, aggression, depression, delusions, wandering, hallucinations and sleep disturbances. “These are frightening for patients and their carers, constitute a serious management problem for psychiatrists, general practitioners and geriatricians, and act as a trigger for admission to institutional care,” says Alistair Burns, a professor of old age psychiatry at the University of Manchester and the author of the BMJ report. Even when a carer can cope with erratic behaviour during the day, disrupted nights often prove the last straw. Non-pharmacological strategies such as behaviour management should be the first line of treatment in goodquality care, says Burns, but all too often powerful sedatives that cause side-effects are prescribed; these include neuroleptic (antipsychotic) drugs designed for schizophrenia.
While medication has a role in some cases, “if you’re asking me whether sedatives are overused, the answer is yes”, says Dr Richard Harvey, the director of research for the Alzheimer’s Society. “A number of studies have shown that anything up to 80 per cent of people in particular nursing homes are on sedatives. For some staff, keeping people comatose and quiet makes for an easy life.”
Although the Department of Health has now forbidden the use of the neuroleptic thioridazine (Melleril) in dementia because it affects the heart, others such as chlorpromazine (Largactil), olanzapine (Zyprexa) and risperidone (Risperdal) are all too often wheeled out. “These drugs have been described as a ‘chemical straitjacket’ or ‘chemical cosh’. They both sedate the person and induce Parkinson’s-like side-effects, stiffness and rigidity. So patients become drowsy and can’t move. They’re more likely to have falls and break their hips. It really is very unpleasant,” Dr Harvey says.
More worryingly, neuroleptics can cause sudden death in the 20 per cent of people with dementia who have DLB (dementia with Lewy bodies), a condition often hard to distinguish from the more common Alzheimer’s disease. But even when patients try to assert some control by refusing to take the tablets, Harvey says — as reported in The Lancet last year — “we found that staff were commonly stirring these drugs into their porridge or soup or even their tea. It was a complete violation of their human rights.”
The Alzheimer’s Society and the National Lottery Community Fund have recently commissioned a study to see whether more support and training for staff can reduce the use of neuroleptics. “We think that it’s a combination of staff being overworked and overstressed and not knowing what to do when faced with challenging behaviour,” he says. He sees the BMJ report as strengthening the case against sedatives and offering a simple and potentially cost-effective alternative that will protect people’s quality of life.
Aromatherapists have been treating residents in nursing homes for at least ten years, usually privately. Anecdotal evidence from nurses and doctors who observed successful results prompted the three aromatherapy trials published in the International Journal of Geriatric Psychiatry and The Journal of Clinical Psychiatry and reported in the BMJ. These trials found a significant beneficial effect on agitation compared with placebo. In contrast to drug trials for dementia, in which 30 per cent of patients are usually unable to complete the process because of side-effects, orsimply because of resistance to taking the drugs, almost all the participants completed the aromatherapy treatment, with no side-effects. Researchers used either essential oils of lemon balm or lavender, added to a carrier oil or cream and applied in a hand and face massage, or inhaled via a diffuser.
Essential plant oils are claimed to have different therapeutic properties that may be psychological or physiological — calming, stimulating, uplifting, antidepressant, anti-inflammatory, antiseptic, analgesic, decongestant. Scent molecules are thought to be absorbed into the bloodstream, either through the skin, nose or lungs, and then to filter into the brain, where they act on the hypothalamus, which influences mood and the hormonal system.
While the link between certain scents and specific results is unclear, researchers at the Institute for Ageing and Health at Newcastle General Hospital who carried out one of the trials on lemon balm oil believe that chemical constituents called terpenes, associated with plant scents, have a cholinergic, or calming, action on brain chemicals known to be affected by dementia, and may work in the same way as anti-dementia drugs such as Aricept.
Light therapy, on the other hand, is an accepted treatment for seasonal affective disorder (SAD), in which people depressed by the lack of light in winter sit before a light box that beams out 10,000 lux of artificial light (the average office is 300 to 500 lux, daylight around 5,000). Dementia is thought to damage the part of the brain controlling the body clock, so that circadian rhythms that regulate the release of the sleep-inducing hormone melatonin are disrupted, especially if exposure to sunlight is also inadequate. An increased amount of bright light is believed to help to “reset” the body clock.
More research is necessary, says Burns. Meanwhile, he advises caution for any carers at home contemplating a DIY rush into either therapy. “In aromatherapy particularly one needs to learn about essential oils and their side-effects, and certainly someone should not be put in front of a light box if it might affect their eyes. These are not things that one should go into without experience.”
Dementia links
www.alzheimers.org.uk — helpline 0845-300 0336 www.ifparoma.org — International Federation of Professional Aromatherapists; 01455-637 987 www.outsidein.co.uk — Outside In (Cambridge), provider of light therapy; 01954-211 955
