As a medical student, I learned about medication and non-medication strategies for reducing symptoms of depression and other neuropsychiatric symptoms (e.g. agitation, anxiety) in people with dementia. While non-medication strategies were emphasized as being preferable, I was taught that we often lacked the time and resources to facilitate their implementation. There was also a sense that people believed that medications worked better—even though we didn’t really know if this was true since studies comparing medication to non-medication strategies were rare. The problem with prescribing medications in this patient population is that medications are associated with potentially catastrophic side effects (e.g. falls and fractures). The distress I felt from navigating this moral dilemma inspired me to undertake a research project looking at the comparative efficacy of interventions for reducing symptoms of depression in people with dementia. Based on my clinical experience as a geriatrician, I hypothesized that non-medication strategies could effectively reduce symptoms of depression because they are addressing its underlying causes.
In the study my co-authors and I demonstrate how non-medication strategies, including animal therapy, exercise, cognitive stimulation, multidisciplinary care, and reminiscence therapy, among others, reduce symptoms of depression in people with dementia in a clinically meaningful way. Further, we present our results in a manner that is readily interpretable by patients, caregivers, and clinicians. Explaining odds ratios and standardized mean differences to patients, caregivers, and clinicians is challenging, but explaining the probability that an intervention will help patients in a clinically meaningful way is much easier. In synthesizing this large body of literature (our systematic review includes 256 studies) and presenting our results in a readily interpretable way (i.e. the probability that an intervention will lead to a clinically meaningful reduction in symptoms of depression for people with dementia), we hope to facilitate patient centred decision making, support the growing number of clinicians who write social prescriptions, and enable policy makers to make evidence informed decisions that will allow people with dementia to live happier lives.
Now, when I reach for my prescription pad, I hope to write many more prescriptions for non-medication interventions (i.e. social prescriptions). I hope that my co-authors and I have given people with dementia, caregivers, clinicians, and policy makers the best evidence yet to support people’s long held assertions that non-medication strategies work as well or better than medications for reducing symptoms of depression in people with dementia. However, I still feel a knot in my stomach because I know there will be patients for whom timely access to multidisciplinary care or non-medication strategies will not be feasible. Our findings must support ongoing advocacy efforts for greater resources to improve social care for people with dementia.
Jennifer Watt is a geriatrician and assistant professor of medicine at the University of Toronto, Canada.
Zahra Goodarzi is a geriatrician and assistant professor of medicine at the University of Calgary, Canada.
Competing interests: please see research paper.