Effective Interventions for Dementia in Mental Health Nursing Advocacy

This critical literature review presents evidence on effective interventions for dementia based on cultural contexts at family and institutional levels to guide mental health nurses' practice.

Running head: EFFECTIVE INTERVENTIONS FOR DEMENTIA
Effective Interventions for Dementia in Mental Health Nursing Advocacy
Name
Institution

EFFECTIVE INTERVENTIONS FOR DEMENTIA
Introduction
Dementia is a mental health condition characterized by the gradual deterioration of
the brain, subsequently affecting different dimensions of a person’s health and associated
quality of life. Individuals with dementia receive care at home or in nursing homes.
Regardless of the setting, mental health nurses have the responsibility of ensuring that the
patients get optimal care aimed at delaying progression of the disease. Identifying effective
interventions is paramount for mental health nurses so that they can support patients and their
caregivers to achieve the goal of slowing down the progression of dementia. The Australian
Institute of Health and Welfare [AIHW] (2019) highlights that dementia affects individuals as
young as those aged 30 years, but a majority of the ailing population falls in the category of
the elderly. In addition to the growing prevalence and incidence rates of dementia, there is
increased diversification of the affected population on the basis of age. People with dementia
are mainly reliant on a caregiver, who is mainly a member of the family, and depending on
the cultural aspect, different outcomes of the care process are realized, emphasizing the
essence of culture in managing dementia, a care management aspect that mental health nurses
should know (Nápoles, Chadiha, Eversley, and Moreno-John, 2010). Thereby, the current
critical literature review aims at presenting the extant evidence on effective interventions for
dementia based on the patients’ and associated care givers’ cultural contexts at family and
institutional levels to form the basis for mental health nurses’ practice.
Physical health conditions like cardiovascular disease and diabetes have received
intensive attention in the past, and they tend to overshadow a need to focus on other equally
deserving facets of health. Mental health conditions have not received the attention they
deserve for a long time; hence, the interventions in place are still undergoing improvements.
Dementia is deemed to be a fatal disease. According to the AIHW (2019), dementia was the
second cause of mortality in 2017. This phenomenon could be attributed to limited attention

EFFECTIVE INTERVENTIONS FOR DEMENTIA
as seen in low investment in management efforts of the condition (Vickland, Morris, Draper,
Low, & Brodaty, 2012). Various propositions are made on the need to use various effective
therapeutic interventions that could help to delay onset of dementia and improve its prognosis
once it is diagnosed. However, the condition continues to be a health issue of concern and
mental health nurses are obliged to identify effective interventions that are culturally
competent to help different patients and their caregivers manage the condition in a meticulous
style. Thereby, the current paper aims to critically review scientific literature on the current
therapeutic interventions for dementia and associated outcomes while taking note of the
cultural aspect to help mental health nurses in their advocacy roles at the community level
and in nursing homes. The review process was conducted through the application of
quantitative research and qualitative research critiquing tools proposed by the University of
South Australia (n. d.). Based on the findings from the primary objective, the secondary
objective, which entails making recommendations for improved practice, will be achieved.
Comparative Definitions of Concepts
Dementia refers to an umbrella of conditions that are identified by the slow
impairment of brain function over time. Alzheimer and vascular dementia are the common
forms of this condition; hence, they will also be used to make inferences to dementia in
articles that use them to refer to dementia. Both conditions can be used to get more
information on dementia as they make up 60% to 80% of dementia cases (Ashraf et al.,
2016). Interventions include all those procedures that aid in the management of the condition
right from the preventive stage to the rehabilitative stage. Culture is an important fact in
health care as it entails the beliefs and values of an individual which affect how individuals
perceive and comprehend problems and the world in general. Cultural variation is not only
between societies, but within societies as well. Thereby, the cultural context in this review
refers to the racial-specific factors as these might have an effect of health outcomes.

EFFECTIVE INTERVENTIONS FOR DEMENTIA
Significance of the Topic
Dementia remains an elusive term for most people, and its effects can extend beyond
the patient depending on the cultural context as indicated by Nápoles et al. (2010). Urses
affect as the perfect media through which family caregivers are able to care for the sick
family member and take care of their own health. It is reported that family caregivers end up
feeling depressed while taking care of dementia patients, and their altered psychological
function has a negative effect on the patients due to factors, such as, gender, culture,
relationship to patient, and personal characteristics. Hence, there is a high rate of nursing
home placement in some cultures compared to others (Etters, Goodall, & Harrison, 2008).
Identifying these effective interventions has a direct impact on nurses in nursing homes,
where they are the main caregivers. Different individuals have different ways of dealing with
the condition, and it is important to understand the different approaches used to come up with
the most effective intervention. A systematic review by Nápoles et al., (2010) in America
indicated that Asians, Africans, Whites, and Latinos have distinct cultural values that affect
the progression of dementia. Such fact finding is compounded by the importance of
addressing individual patient needs (Cohen-Mansfield, Golander, Arnheim, & Cohen, 2014).
Despite the existence of effective interventions, barriers and hindrances at the
institutional level thwart successful implementation of these interventions. Leadership plays a
pivotal role in ensuring that effective interventions are used in institutions. The fact that
nursing standards advocate for leadership abilities, by identifying effective interventions for
dementia patients, nurses use their influence to solicit support from the management where
they work to facilitate implementation of the interventions. Otherwise, inadequate and lack of
well-defined interventions do not reduce the current high incidence and prevalence rates. As
the population continues to be characterized by a large percentage of elderly individuals,

EFFECTIVE INTERVENTIONS FOR DEMENTIA
dementia will overburden the healthcare system if the right and effective approaches are not
adapted at both family and institutional levels.
Search Strategy and Justification of Use of Literature
Data Sources
Guided by the topic of this literature review, various databases were used to retrieve
the articles for this review, and these included: PubMed, Wiley, Hindawi, Science Direct and
Semantic Scholar. Only those articles whose full preview was available were included in the
current study. The keywords used to develop search strings were “Dementia,” or “Alzheimer”
“Effective Therapy” “Culture” or “Cultural Context” “Effective Interventions” or “Effective
Therapeutic Interventions” and “Australia”.
Inclusions and Exclusions
The review included articles using both qualitative and quantitative research
approaches conducted across the world. The essence is to help in identifying therapeutic
interventions in Australia and use a worldwide perspective to address the secondary
objective. Research articles where qualitative and quantitative were used were included.
Other systematic reviews were not included in this review, and only those articles published
in English were used. There are few studies on the topic in Australia, and this could explain
the high prevalence of dementia as the condition has received little attention in this region.
Data Extraction
Different search strings yielded different hits that were managed using filters.
Ultimately, 7 articles were derived from the Wiley database, 3 from Pubmed, 2 from Science
Direct, and 1 from Semantic Scholar.
Results
All the 13 articles were included in this review as they were relevant and met the
inclusion criteria. These articles included adopted an array of research methods that ranged

EFFECTIVE INTERVENTIONS FOR DEMENTIA
from experimental research, cross-sectional design, mixed-methods study, and qualitative
research.
Description of Relevant Concepts
Cultural Concept. A society on the basis of nationality or race consists of different sub-
cultures based on socioeconomic status, gender, and ethnicity. The articles described herein
are not articulate on the basis of culture, but they give implication on the alignment of
interventions to cultural values and beliefs in a familial context. However, due to the fact that
nursing homes are also included, culture in this review also includes organizational culture as
each institution is guided by a distinct frame of values and rules.
Art Therapy. One of the interventions that proved effective was art therapy where different
studies indicated the use of different approaches in nursing homes. Art therapy in this review
indicates the use of artistic media to engage individuals with dementia and help them manage
different spheres of their individuality, such as, their feelings, emotions, inner conflict, self-
awareness, behavior, and personality (Wang & Li, 2016).
Critical Analysis of the Literature
Two major themes emerged from the review of 13 articles. Interventions for dementia can be
classified into preventive and rehabilitative interventions because there is no absolute cur for
dementia. Thereby, the interventions, as reviewed below, are explored based on these two
categories.
a. Preventive
i. Screening
Takeda, Nakagome, Tajime, and Saito (2009) developed a simple and efficient tool: the
Takeda Three Colors Combination Test (TTCC), which is different from the typical
screening tests as it can be used by non-specialists. The TTCC was first tested in Japan but
could be tested in other cultural settings to ascertain its validity and reliability across cultures.

EFFECTIVE INTERVENTIONS FOR DEMENTIA
Sayegh and Knight (2013) indicated an interesting aspect of ethnic-specific variation in the
diagnosis of dementia using behavioral and psychological symptoms. They used a cross-
sectional approach to diagnose dementia using neuropsychological test performance,
behavioral and psychological symptoms and informant reports on functional abilities of
patients among Hispanics and Whites. Thereby, it is important for care providers to adapt the
use of diagnostic strategies to ensure efficacy, and this can be attained through research.
Nurses develop educational material to inform community members about the red flags that
warrant screening.
ii. Multidomain Intervention
A randomized trial by Rosenberg et al. (2017) aimed to determine the effect of diet,
cognition, exercise, and vascular risk management (multidomain intervention) on incidence
of dementia. Regardless of the baseline characteristics of the participants in reference to their
sociodemographic profile. Thereby, when screening is followed by a multidomain
intervention, onset of dementia is delayed and progression of the disease is reduced. Nurses
should be aware of the multifaceted care approach for dementia patients so that they are able
to apply their leadership and communication skills to engage the different care providers, for
example, cardiologists and nutritionists.
b. Rehabilitative
i. Staff and Familial Empowerment
Individuals with dementia need people to take care of them and based on the societal culture
of different individuals, the approach taken is different. Some individuals usually send their
affected family members to nursing homes while others will prefer to take care of their loved
ones. Family care givers need to be constantly motivated and engaged by nursing who need
to have up-to-date evidence to help these caregivers employ effective strategies. Nursing
home staff employ different caring approaches, and among them is restraining these

EFFECTIVE INTERVENTIONS FOR DEMENTIA
individuals with dementia. A mixed method study by Jacobsen et al. (2017) indicated that an
educational intervention helps to increase the knowledge levels of the staff because they did
not know that some of the approaches they used, for example, bedrails, were restrictive.
Instead, they regarded them as protective. However, educational intervention about caring for
dementia patients based on restraint versus confidence initiatives, alone, did not emerge an
effective intervention for dementia patients. The organizational culture as influence by the
leadership in place, should be considered when implementing any intervention in a nursing
home to aid in caring for dementia patients. The person-centered approach meant to instill
confidence among patients was also tested by Gillis et al., and it revealed improved outcomes
marked by reduced frequency and severity of aggression, improved decorum, and reduced
depression among dementia patients (2019). Residents with dementia were involved in either
therapeutic touch, music therapy, or meaningful individual activities as guided by the ABC
method along with the Senses Framework. Such a person-centered approach should be
executed by the entire team to help fulfill the needs across the residents in the nursing homes.
Nurses take on leadership roles to advocate for change in implementing effective therapeutic
interventions for their dementia patients in nursing homes.
Care providers for dementia patients should be in good health to project positive
attitude and initiatives to their patients. Thereby, effective interventions are made possible if
care providers can deliver effective interventions. As a result, effective interventions begin
with staff or familial empowerment through interventions aimed at reducing and improving
coping strategies with stress, time management, and positive living strategies, as elaborated
by Ali and Bokharey (2015). There are many studies on how to enhance the effectiveness of
carers for dementia patients as their wellbeing is projected to their patients.
ii. Cognitive Stimulation Therapy

EFFECTIVE INTERVENTIONS FOR DEMENTIA
A mixed methods study sought to establish the suitability of the cognitive stimulation
therapy approach that has proved effective in western cultures in the Chinese culture. The
intervention was adapted to fit the Chinese culture and proved effective through prevention of
cognitive deterioration and improved adherence (Wong, Yek, Zhang, Lum, & Spector, 2018).
In Chennai, India, a qualitative study by Raghuraman, Lakshminarayanan, Vaitheswaran, and
Rangaswamy (2017), adaptation of the cognitive stimulation therapy to align it to the Indian
culture was found to be acceptable, relevant, and enjoyable. The study, however, should be
followed by a quantitative study to ascertain its efficacy.
iii. Art Therapy
Doll therapy was shown to reduce behavioral and psychological symptoms of
dementia as indicated by Cantarella, Borella, Faggian, Navuzzi, and De Beni (2018). Doll
therapy is ideal for use in a nursing home, but its implementation is dependent on various
institutional factors as noted earlier in a study by Jacobsen et al. (2017). The therapy
approach, however, was not effective in improving eating behavior. An experimental study
by Lin et al. (2011) indicated the efficacy of group music interventions in ameliorating
agitation among elderly individuals with dementia. The study by Gillis et al. (2019) also
indicated the use of group music sessions to engage individuals with dementia as a
confidence-based initiative which proved to be beneficial in improving health behavioral and
psychological outcomes. An earlier study by Li and Li (2016) indicated significant
improvements in cognitive function, behavioral and psychological symptoms, as well as
quality of life in a Chinese population of elderly individuals with dementia.
iv. Multi-Sensory Interventions
A study by Bauer, Rauner, Koch, and Chenco (2012) indicated the use of multi-
sensory interventions in Victoria, Australia. The study, however, criticized the use of these
interventions due to lack of a clear protocol to guide their use in reference to the description

EFFECTIVE INTERVENTIONS FOR DEMENTIA
of these interventions, guidelines for use, and lack of skills on their use among the staff in the
residential aged care facilities. This study highlights the need for research, and especially
evaluative studies for the care processes for individuals with dementia in Australia.
Recommendations for Practice
There is limited attention on this topic in Australia; hence, this paper acts as a good
basis for creating awareness on the need to focus on dementia, effective interventions as per
the current evidence, and guiding subsequent research. There are various culturally sensitive
care models that remain untested (National Collaborating Centre for Medical Health (UK),
2007; Daire & Mitcham-Smith, 2011; Wang & Li, 2016). Therefore, there is need to engage
in more rigorous research to establish the adaptation of scientific practices and cultural
beliefs and values while evaluating their effectiveness. Interventions, such as multi-sensory
interventions, are used without clear formal guidelines. Research on adaptation of art therapy
in a home environment in alignment with the cultural system would suffice. Nurses have the
important role of advocating for mental health through engaging family members in the
community and seeking change in nursing homes by presenting their plans to the
management on how to successfully integrate the different effective interventions that have
been discussed above.
Conclusion
Different individuals based on their culture have different ways of handling
individuals with dementia. Regardless, of the approach, it is important to ensure that the
interventions are optimal to help in alleviating progression of the ailment and preventing
extension of dementia beyond the patient. Thereby, the current literature review aimed to
critically analyze literature to establish effective interventions for dementia in a cultural
context. Two major themes emerged: preventive and rehabilitative interventions. Sub-themes
included screening, staff empowerment. There is increased support for art therapy in a

EFFECTIVE INTERVENTIONS FOR DEMENTIA
nursing home context, but this therapy has not yet been integrated into the family setting.
Recommendations were made for both the family institution and nursing homes.

EFFECTIVE INTERVENTIONS FOR DEMENTIA
References
Ali, S., & Bokharey, I. Z. (2015). Efficacy of cognitive Behavior Therapy among Caregivers
of Dementia: An Outcome Study. Pakistan Journal of Psychological Research, 30(2),
249-269.
Australian Institute of Health and Welfare [AIHW]. (2019). Dementia. Retrieved from
https://www.aihw.gov.au/reports-data/health-conditions-disability-
deaths/dementia/overview.
Bauer, M., Rayner, J., Koch, S., & Chenco, C. (2012). The Use of Multi-Sensory
Interventions to Manage Dementia-Related Behaviors in the Residential Aged Care
Setting: A Survey of One Australian State. Journal of Clinical Nursing, 21(21-22),
3061-3069.
Cantarella, A., Borella, E., Faggian, S., Navuzzi, A., & De Beni, R. (2017). Using Dolls for
Therapeutic Purposes: A Study on Nursing Home Residents with Severe Dementia.
Geriatric Psychiatry, 33(7), 915-925.
Cohen-Mansfield, J., Golander, H., Arnheim, G., & Cohen, R. (2014). Reactions and
Interventions for Delusions in Nursing Home Residents with Dementia. American
Journal of Alzheimer’s Disease and Other Dementias, 29(4), 386-394.
Daire, A. P., & Mitcham-Smith, M. (2006). Culturally Sensitive Dementia Caregiving
Models and Clinical Practice. Adult Span Journal, 5(1), 25-35.
Etters, L., Goodall, D., & Harrison, B. E. (2008). Caregiver Burden among Dementia Patient
Caregivers: A Review of the Literature. Journal of American Academy of Nurse
Practitioners, 20(8), 423-428.
Gillis, K., Lahay, H., Dom, S., Lips, D., Arnouts, H., & Bogaert, P.V. (2019). A Person-
Centered Team Approach Targeting Agitated and Aggressive Behavior amongst
Nursing Home Residents with Dementia Using the Senses Framework. International

EFFECTIVE INTERVENTIONS FOR DEMENTIA
Journal of Older People Nursing. Retrieved from
https://onlinelibrary.wiley.com/doi/10.1111/opn.12269.
Jacobsen, F. F., Mekki, T. E., Førland, O., Folkestad, B., Kirkevold, Ø., Skår, R., … Øye, C.
(2017). A Mixed Method Study of an Education Intervention to Reduce Use of
Restraint and Implement Person-Centered Dementia Care in Nursing Homes. BMC
Nursing, 16, 55. Doi: 10.1186/s12912-017-0244-0.
Lin, Y., Chu, H., Yang, C., Chen, C., Chen, S., Chang, H., … Chou, K. (2011). Effectiveness
of Group Music Intervention against Agitated Behavior in Elderly Persons with
Dementia. International Journal of Geriatric Psychiatry, 26(7), 670-678.
Li, D., & Li, X. (2016). The Effect of Folk Recreation Program in Improving Symptoms: A
Study of Chinese Elder Dementia Patients. International Journal of Geriatric
Psychiatry, 32(8), 901-908.
Napoles, A. M., Chadiha, L., Eversley, R., & Moreno-John, G. (2010). Reviews: Developing
Culturally Sensitive Dementia Caregiver Interventions: Are We There Yet?.
American journal of Alzheimer's disease and other dementias, 25(5), 389–406. Doi:
10.1177/1533317510370957.
National Collaborating Centre for Mental Health (UK) (2007). Dementia: A NICE-SCIE
Guideline on Supporting People with Dementia and Their Carers in Health and
Social Care. Leicester (UK): British Psychological Society.
Raghuraman, S., Lakshminarayanan, M., Vaitheswaran, S., & Rangaswamy, T. (2017).
Cognitive Stimulation Therapy for Dementia: Pilot Studies of Acceptability and
Feasibility of Cultural Adaptation for India. The American Journal of Geriatric
Psychiatry, 25(9), 1029-1032.
Rosenberg, A., Ngandu, T., Rusanen, M., Antikainen, R. L., Bäckman, L., Havulinna, S., …
Kivipelto, M. (2017). Multidomain Lifestyle Intervention Benefits a Large Elderly

EFFECTIVE INTERVENTIONS FOR DEMENTIA
Population at Risk for Cognitive Decline and Dementia Regardless of Baseline
Characteristics: The FINGER Trial. Alzheimer’s & Dementia, 14, 263-270.
Sayegh, P., & Knight, B. G. (2013). Assessment and Diagnosis of Dementia in Hispanic and
non-Hispanic White Outpatients. The Gerontologist, 53(5), 760–769.
Doi:10.1093/geront/gns190.
Takeda, S., Nakagome, K., Tajime, K., & Saito, M. (2009). Effectiveness of the Takeda
Colors Combination Test as a Screening Test for Dementia. Psychogeriatrics, 9(1), 4-
10.
University of South Australia. (n. d.). Critical Appraisal Tools. Retrieved from
https://www.unisa.edu.au/research/Health-Research/Research/Allied-Health-
Evidence/Resources/CAT/
Vickland, V., Morris, T., Draper, B., Low, L. F., & Brodaty, H. (2012). Modelling the Impact
of Interventions to Delay the Onset of Dementia in Australia. New South of Wales:
Alzheimer’s Australia.
Wang, Q., & Li, D. (2016). Advances in Art Therapy for Patients with Dementia. Chinese
Nursing Research, 3(3), 105-108.
Wong, G. H., Yek, O. P., Zhang, A. Y., Lum, T. Y., & Spector, A. (2018). Cultural
Adaptation of Cognitive Stimulation Therapy (CST) for Chinese People with
Dementia: Multicentre Pilot Study. . International Journal of Geriatric Psychiatry,
33(6), 841-848.