Oliver James: Family under the microscope

Alzheimer's need not mean a life sentence of depression and misery

Is it inevitable that your parent with Alzheimer's disease – or another dementia, such as one caused by a stroke – is not only going to have a memory problem but also be mentally ill? Is there anything you can do to avoid this? I am glad to report that there is.

There is no doubt that elderly people with Alzheimer's are more likely to suffer from psychoses, depression and anxiety when compared with their peers without this illness. Psychiatrists tend to assume that the greater proneness to confusion and mental illness is neurological, a biological correlate of the brain damage entailed by Alzheimer's. They are wrong. What makes them mentally ill is the way sufferers are managed.

Of the 200,000 who are in a care home, half are medicated with the same anti-psychotic drugs used to control the hallucinations, delusions and abnormal behaviour found in schizophrenics. One quarter of these drugged patients die prematurely as a direct consequence of the side-effects.

It is understandable that these drugs are so often used, as conventional care methods for managing Alzheimer's are not at all effective. A review of all the studies of the main methods suggests they are mostly, and in a few cases worse than, useless.

One widely used method is reality orientation (RO), in which sufferers are constantly prompted with facts about the date, time, names and so on in their environment. The review finds that, despite its "frequent clinical use", there is no reliable evidence that it improves the patient's wellbeing or reduces behavioural problems. It concludes that RO "is not useful".

Guidelines from Nice (the National Institute for Health and Clinical Excellence) suggest the use of cognitive behavioural therapy, but the review finds no evidence that it achieves any sustained improvements over time. While some studies of poor quality find that it can temporarily improve mood, others do not replicate this.

Validation therapy (VT) aims to provide an opportunity to resolve life's unfinished conflicts by encouraging the expression of feelings and validating them. It was shown to increase patients' conversational attempts in a few cases. However, when the therapy was independently evaluated, the raters found no difference in emotional outcome, nursing time required or prescription of anti-psychotic medication, although nursing staff believed VT had helped.

Finally, reminiscence therapy makes use of old newspapers, songs and household items to stimulate memories and discussion. Alas, again, there was little to recommend it.

Small wonder, then, that many Alzheimer's patients are mentally ill and that desperate staff prescribe anti-psychotics. Yet it need not be so. Once you realise that the only significant disability of Alzheimer's sufferers is a lack of short-term memory and that there is good evidence their long-term memory is usually working until the end of life, life-long wellbeing is very feasible. If carers develop a profile of the individual patient's favourite old memories, they can create a kind of happy Groundhog Day.

Applauded in past appraisals by the Royal College of Nursing and the Alzheimer's Society, the Specal method (Specialised Early Care for Alzheimer's, described in my book Contented Dementia), has three simple tenets: don't ask questions; never contradict the patient; and learn to love their repetitiveness. Try them – thousands of carers and patients all over the country are already gaining relief from doing so. As Lord McColl, a shadow health minister, stated in a recent House of Lords debate, Specal "is the only management method which seems to confer contentment".

Review of evidence: Livingston, G et al, 2005, American Journal of Psychiatry, 162: 1996-2021. For Lord McColl's speech go to selfishcapitalist.com