Characteristics, outcomes, facilitators and barriers for psychosocial interventions on inpatient mental health dementia wards: a systematic review

Background The National Institute for Health and Care Excellence guidelines state that psychosocial interventions should be the first line of treatment for people with dementia who are experiencing distress behaviours, such as agitation and depression. However, little is known about the characteristics and outcomes of psychosocial interventions or the facilitators and barriers to implementation on inpatient mental health dementia wards which provide care for people with dementia who are often experiencing high levels of distress. Methods A systematic search was conducted on MEDLINE, CINAHL, PsycINFO, Psychology and Behavioural Sciences Collection, and Scopus in May 2023, following PRISMA guidelines. Reference and citation searches were conducted on included articles. Peer-reviewed literature of any study design, relating to psychosocial interventions in inpatient mental health dementia wards, was included. One author reviewed all articles, with a third of results reviewed independently by a second author. Data were extracted to a bespoke form and synthesised using a narrative review. The quality of included studies was appraised using the Mixed Methods Appraisal Tool. Results Sixteen studies were included in the synthesis, which together included a total of 538 people with dementia. Study methods and quality varied. Psychosocial interventions delivered on wards included music therapy (five studies), multisensory interventions (four studies), multicomponent interventions (two studies), technology-based interventions (two studies), massage interventions (two studies) and physical exercise (one study). Reduction in distress and improvement in wellbeing was demonstrated inconsistently across studies. Delivering interventions in a caring and individualised way responding to patient need facilitated implementation. Lack of staff time and understanding of interventions, as well as high levels of staff turnover, were barriers to implementation. Conclusion This review highlights a striking lack of research and therefore evidence base for the use of psychosocial interventions to reduce distress in this vulnerable population, despite current healthcare guidelines. More research is needed to understand which psychosocial interventions can reduce distress and improve wellbeing on inpatient mental health dementia wards, and how interventions should be delivered, to establish clinical and cost effectiveness and minimise staff burden. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-024-04965-8.


Background
The already high prevalence of dementia and the significant predicted increase in those diagnosed with the condition in the coming decades has been widely documented [1].Behavioural and psychological symptoms of dementia, which can include agitation, anxiety, depression, sleep disturbances, hallucinations, apathy, and disinhibition, are experienced by 80% of people with dementia in the UK [2].Throughout this paper we refer to these as distress or distress behaviours, using preferred language by people with dementia reflecting that distress can be caused by symptoms of dementia and/or be an expression of unmet needs [3].
Inpatient mental health dementia wards, also known as psychiatric wards, provide care for people with dementia experiencing acute levels of distress that is putting their safety or the safety of others at risk [4,5].The aim of the mental health admission is to assess and treat the crisis, including distress behaviours.In the UK, people are often detained using the provisions of the Mental Health Act 2007 meaning they can be treated without their consent, and admission often follows a breakdown of care in the home or care home, which can be traumatic for the person with dementia and their family caregiver(s) [6,7].Caring for this population is complex as many have multiple long term conditions, and may need palliative care as they come to end of life [5,8].A recent systematic review of the characteristics and outcomes of patients on these wards internationally highlights that little is known about current standards of practice and how best to deliver care in this setting [5].
The National Institute for Health and Care Excellence (NICE), who provide evidence-based recommendations for care in the UK, emphasise that psychosocial interventions, also described as nonpharmacological interventions, should be the first line of treatment for distress behaviours in dementia care [9].NICE defines psychosocial interventions as interventions that require specific competencies for delivery, are supported by relevant training and supervision, and provide an enhanced level of intervention [10].
Increasingly such interventions are manualised and their effectiveness to reduce distress and support wellbeing for people with dementia in residential care settings has been tested [11][12][13].However, there are still significant gaps in dementia care research and practice [14].In particular, little is known about what psychosocial interventions have been delivered in inpatient mental health dementia care, and whether these were helpful.This is concerning as these wards provide specialist care for those who cannot be safely cared for in residential care, and pharmacological interventions, such as antipsychotic medication, are frequently used to manage distress with concomitant increase in risk of falls, strokes and death [4,15].Further understanding of the current research on inpatient mental health dementia wards, including which psychosocial interventions have been delivered and how, positive and negative patient outcomes, and the facilitators and barriers to implementation, is needed to inform future research and practice.
To understand the current literature on this topic, a systematic review of psychosocial interventions in inpatient mental health dementia care was conducted.Based on expert-by-experience and stakeholder feedback, the review focussed on interventions that aim to reduce distress or improve wellbeing for people with dementia, as this is the primary focus of the admission.The following review questions were established:

Methods
This systematic review follows the PRISMA reporting guidelines, and is registered on PROSPERO (CRD42023429983) [16].impairment" OR "memory loss") AND (psychosocial OR psychological OR psychotherapy OR mental health intervention OR nonpharmacological OR person-centred).

Search strategy
Search results were exported to an online software, Rayyan, for screening [17].All titles and abstracts were screened by NT, with one third of results independently reviewed by EW.Where there was uncertainty, the full text was retrieved.Screening of the full texts was conducted by NT, with one third independently reviewed by EW.All reasons for exclusion were recorded.At both stages of screening, discrepancies were resolved between the two authors following discussion.Where additional information was required to inform inclusion decisions, authors were contacted via email.
Quality assessment of all included articles was conducted by NT using the Mixed Methods Appraisal Tool (MMAT), with one third conducted independently by EW [18].This tool is not designed to give a score or inform inclusion and exclusion decisions, but provides a framework for assessing qualitative, quantitative and mixed methods studies.One article included authors of this current review (NT, HOM, and BRU) and so was assessed by EW to minimise bias.In case of uncertainty or discrepancies, decisions were discussed between NT and EW to reach consensus without the need to involve a third reviewer.

Inclusion and exclusion criteria
Inclusion and exclusion criteria were developed and outlined using an adapted PICOS framework (see Supplementary File 1 for justification for the criteria):  [20].Facilitators and barriers to implementation were coded using inductive coding, and grouped into themes using thematic analysis [21].Based on a previous scoping of the literature, interventions were grouped by type of intervention.Where there were two or more studies looking at a similar intervention these were combined to create a new category.
Where studies reported outcomes not relating to people with dementia, for example for staff or family members, data were not extracted as this is outside the scope of the review questions.

Results
The online searches retrieved 1221 articles.After removal of 355 duplicates, 866 titles and abstracts were screened.Of these, 835 articles were excluded, with full texts retrieved for 31 articles.Eight articles met the inclusion criteria (see Figure 1 for exclusion reasons).An additional eight articles were included from searching reference lists and citation searches of included articles.A total of 16 articles, involving 16 separate studies, are included in this review.
The majority of studies investigated a psychosocial intervention on one inpatient mental health ward, while one looked at two wards [34], and another included three wards [26].There was a combined total of 538 participants across studies, ranging from four to 175 participants.For details of participant characteristics, see Table 1.

Quality Appraisal
Results from the MMAT showed the varying quality of the included studies, with an average (both mean and mode) of four out of seven criteria met across all studies, ranging from one to seven (l Supplementary File 2).The two screening questions applied to all studies were not consistently met, with two studies not clearly stating the research questions [30,36], and four not clearly demonstrating they collected appropriate data to answer research questions [22,30,35,36].However, due to the small number of studies meeting inclusion criteria, these are included in the synthesis.

Intervention outcomes Music therapy intervention outcomes
A reduction in agitation and distress behaviours, and increase in positive moods and behaviours, was reported in four of the five music therapy interventions on days when the intervention was delivered [29,34,36,37], one of which also reporting a reduction in biomarkers for stress [29].Two of these studies found that a minority of participants displayed increased frustration or agitation during group music therapy sessions [36,37].One study suggested that this could be a response from the participant to being drawn out of passivity [36], and another that the open nature of the group enabled participants to leave if they chose to [37].However, one study reported no reduction in agitation or distress behaviours when music therapy was compared to an active control, though the groups were not comparable at baseline and it was not clear whether participants had adhered to the assigned intervention [25].

Multisensory intervention outcomes
All of the multisensory interventions reported short term positive outcomes relating to reduction in agitation and distress behaviours and increases in positive moods and interactive behaviours during sessions [24,30,31,33], with one study reporting this lasted up to one hour post intervention [30].Additional reported outcomes were improved independence in activities of daily living [24], and reduction in apathy [24].No change was reported for aggressive behaviours [30], wellbeing [31], heart rate [33], and prescribed medication [24].

Multicomponent, massage, technology-based and physical exercise intervention outcomes
Outcomes for massage interventions were inconclusive.Two studies reported a reduction in biomarkers for stress following massage [23,27], with one study, which accounted for confounding factors in the analysis, reaching statistical significance [27].One study found no change in cognition but a significant reduction in aggression [27], while one found no difference in agitation [23], although authors suggest this could be because scores for agitation were low at baseline, and quality assessment showed that reported outcome data were not complete.
For multicomponent interventions, reported outcomes were conflicting.One study reported short term development of group cohesion, reduction in anxiety and changes in social interactions following weekly movement and sensory stimulation groups [22].However, another found no significant differences between the intervention group, receiving group and individual music and physical exercise, and a control group of previous patient cohorts receiving standard care, although data suggested a reduction in anxiety and worsening of sleep and nighttime behaviour [28].This study was a randomised controlled trial with a large number of participants, but it was not clear whether the intervention was administered as intended and confounding factors were not accounted for in the design and analysis.
Reported findings for technology-based interventions suggest positive changes in mood and reduction in anxiety, agitation and resistance to care [32,35].However, one intervention using simulated presence through recorded videos of family members, found that videos with too many people could cause a negative response [35].
Finally, a study of a physical exercise intervention found a significant reduction in agitation, lability and verbal aggression in the intervention group, but no reduction in physical aggression or prescribed medication [26].This study also reported that participants did not adhere to the assigned intervention.

Facilitators and barriers to implementation
All except one [31] of the included studies reported facilitators and/or barriers to implementation of the psychosocial intervention in the ward setting.Most were reported by the researchers, but some were reflections from staff, with one [37] also including feedback from family members.Inductive coding of reported facilitators and barriers led to the emergence of three themes: factors relating to the interventionist, factors relating to the intervention, and factors relating to the ward environment.

Factors relating to the interventionist
Researchers, staff and family members reported that staff support and understanding of the intervention, and delivering it with a caring approach enabling patients to express themselves and interact as they were able in the moment, facilitated implementation [22,32,34,35,37].Researchers reported that the provision of supervision supported understanding [32], and family members and staff stated that observing the positive effects of the intervention with opportunities for positive interactions with patients were additional facilitators [37].One study reported that nurse initiation of the intervention without referral to more senior staff members for approval supported implementation [30].Barriers to implementation support these findings, with five studies, two of which reported staff feedback, stating that lack of understanding, scepticism of the intervention, and resistance to having close relationships with patients, were barriers to implementation and effectiveness [23,27,34,35,37].This included staff reported fears about using equipment incorrectly or causing negative effects [33].

Factors relating to the intervention
Seven studies, two reporting staff responses, stated that the ability to individualise the intervention to patient preference, ability and the patient's culture facilitated implementation [22,24,29,30,32,34,37].In addition, researchers and staff in four studies reported that utilising nonverbal methods of communication, such as touch and music, enabled emotional expression, increased engagement and attention, and helped deepen the relationship between participants [27,29,34,37].Other facilitating elements reported by researchers were safe, easy and accessible delivery [35], and gradually increasing the length of the intervention [24], while staff reported using good quality video and audio materials as supporting factors [35].Factors reported by researchers as barriers to implementation of interventions were overstimulation for the person with dementia [35], and not being tailored to the cognitive abilities of the individual, such as concentration, with one study reporting that this was particularly evident towards the beginning of the hospital stay [28,35].Additionally, how interventions were introduced to the wards could be a barrier to implementation including a lack of clear plans for implementation in the design [33], and introducing multiple interventions simultaneously [28].

Factors relating to the ward environment
Elements relating to the ward environment were cited as both facilitators and barriers to implementation.Enabling factors reported by staff and researchers were the ability to create a calm space on the ward [22,35], regular intervention delivery, which may enable a trusting relationship to be established between patient and interventionist [23,26,27,29], and timing the intervention around patients' needs and ward routines [23,26,27].Inhibiting factors reported by researchers were rigid timing of intervention delivery to fit around ward routines [23], a clinical focus on behaviour rather than mood on the ward [36], lack of staff time to support and deliver interventions [28,37], high levels of staff turnover, and not having regular access to an appropriate space [33].In addition, one study suggested that patients being in late stages of dementia could be a barrier to engaging in interventions [25].However, in this study, treatment groups were not comparable at baseline and the intervention did not appear to be individualised to the patient [25].

Discussion
This review provides a systematic, narrative analysis of psychosocial interventions reported on inpatient mental health dementia wards, the outcomes for patients, staff and families, and the factors influencing implementation.The 16 included studies were small and of varying quality, but suggest that psychosocial interventions may help reduce distress experienced by people with dementia on these wards.The lack of good quality research is particularly striking given that NICE guidelines call for psychosocial interventions as the first line of treatment for people with dementia experiencing distress, and these wards provide care for those experiencing the highest levels of distress in our communities [4,9].There is therefore a critical need for more research in this area, as reported in previous systematic reviews [5].
The research included in this review was of varying methodological quality and mostly in early stages of research development, with small samples and using single sites.This is reflected in the results of the MMAT with studies not consistently stating the research questions or demonstrating data collected were appropriate to answer research questions.This limits the comparability of results between studies, and the generalisability of findings to other settings.In addition, justification for the chosen intervention, the way it was delivered, and the theory for how and why it is expected to reduce distress and improve wellbeing, was poorly reported.
Overall findings suggest that psychosocial interventions, in particular music therapy and multisensory interventions, may be helpful in reducing distress and potentially improving wellbeing, although findings were not consistent.This is supported by a reduction in stress biomarkers in some included studies, suggesting interventions could have a biophysiological impact on people with dementia which enables a reduction in distress [23,27,29].However, the need for careful intervention design and delivery were highlighted by reported negative outcomes including worsening sleep behaviour and overstimulation [28,35].The potential challenges of implementing psychosocial interventions in this ward environment were shown.In particular, most interventions relied on staff for delivery, but lack of staff time and understanding of the intervention, and high levels of staff turnover, were barriers to implementation.
Findings from this review suggest that psychosocial interventions should be mainly nonverbal, personcentred, culturally sensitive, and delivered flexibly by a trained and skilled interventionist who is able to respond and regulate arousal in the moment.They should also minimise reliance on staff to deliver them and provide adequate training for staff to understand the potential benefits of the intervention.This has implications for policy, with psychosocial interventions reviewed against these criteria to increase their usefulness and helpfulness in reducing distress for people with dementia on mental health wards.In particular, policies should support training for staff to deliver specific psychosocial interventions, with accompanying funding for this post above the current staffing on wards, and the inclusion of mandatory training on interventions for all staff.Additionally, policies should include the development of standards for dementia friendly ward environments to ensure that psychosocial interventions can be implemented, including having private spaces available to deliver individual and small group interventions.
However, included studies do not provide evidence for which interventions should be delivered, how and when to deliver them, the support needed for implementation, and how this links with the wider care plan and support for the individual.There was also a lack of evidence for the involvement and impact for family members, with only one [37] study mentioning their involvement.Future research should consult current guidelines on developing and evaluating complex interventions, such as those from the Medical Research Council [38].Involving people with lived experience, such as staff, family members and patients, in the design of interventions and studies will be crucial to supporting feasibility of delivery and helpfulness [39,40].Once these factors are identified, multi-site, randomised and masked studies are needed to establish clinical and cost effectiveness.Outcomes should include the effectiveness of interventions to reduce distress, with definitions and outcome measures agreed with staff, patients and family members; the cost-effectiveness of the intervention; the impact on staff time, care delivery and the ward environment; the impact on patient, staff and family member wellbeing; the impact on patient length of stay, including communication with the discharge destination; and the impact on use of as-needed (pro re nata) and prescribed medication.
Limitations of this review include the use of a second reviewer for only one third of the titles and abstracts and full text articles during the screening process meaning it is possible that articles were wrongly excluded during screening.Only articles written in English were included due to resource limitations, and articles not published in peer-review journals were excluded, potentially missing ward-based evaluations and audits.Additionally, the varied language used to describe inpatient mental health wards internationally further complicated the screening process.Studies specifying they took place on hospital wards and focused on distress behaviours in dementia were included, and any uncertainties were discussed with the team.Due to the small number of studies expected to meet the criteria a time limit was not used so some studies may not reflect current practice.

Conclusion
Further research is required to increase our understanding of whether specific psychosocial interventions can help reduce distress and improve wellbeing for people with dementia on inpatient mental health dementia wards, and how these should be delivered.This can enable the development of cost-effective toolkits and protocols for psychosocial interventions that are feasible to deliver with limited resource and have been shown to reduce distress and improve wellbeing on inpatient mental health dementia wards.

Fig. 1
Fig. 1 PRISMA diagram of study selection procedure health dementia wards, and how interventions should be delivered, to establish clinical and cost effectiveness and minimise staff burden.
of included studies were examined, and backward and forward citation searches conducted on Google Scholar.Search terms were: (old* OR elder* OR geriatric* OR senior*) AND ((Psychiatr* OR psychogeriatric* OR "mental health") N2 (inpatient* OR ward* OR unit* OR acute)) AND (dementia OR alzheimer* OR "cognitive mental

Table 1
Study key characteristics