An overview of some effective non-pharmacological approaches to treating the behavioral and psychological symptoms of dementia

1. Changing Treatment to
Change Behavior
Non-Pharmacological Approaches to Treating the
Behavioral and Psychological Symptoms of Dementia
Paige Thompson
Spring 2015

2. BPSD (Behavioral and Psychological
Symptoms of Dementia)
• Common BPSD include agitation, aggression, mood disorders and
psychosis, but other important symptoms include sexual disinhibition,
eating problems and abnormal vocalizations. (Douglas et al.)
• BPSDs are a common reason for institutionalization of people with
dementia and they increase the burden and stress of caregivers (Douglas
et al.)
• 2 types:
• behavioral excesses (such as disruptive vocalization or aggression)
• behavioral deficits (such as lack of social interaction or lack of self-care)
(Douglas et al.)
• 4 subtypes
• Physically aggressive behaviors (Hitting, kicking, biting)
• Physically nonaggressive behaviors (Pacing, inappropriately handling
objects, wandering)
• Verbally nonaggressive agitation (Constant repetition of sentences or
requests)
• Verbal aggression (Cursing, screaming) (Colón)

3. Identifying an underlying cause
• “Good clinical practice requires the clinician first to exclude the
possibility that behavioral or psychological symptoms are the
consequence of concurrent physical illness (e.g. infections,
constipation), and second to try nonpharmacological approaches
before considering pharmacological interventions.” (Douglas et al.)
• Behavioral symptoms often communicate and underlying issue: obtain
or meet a need (e.g. pacing to provide stimulation); communicate a
need (e.g. repetitive questioning); or an unmet need (e.g. aggression
triggered by pain or discomfort) (Douglas et al.)
• The fastest way to “quiet” behaviors is through an antipsychotic, but
once pharmacological treatment starts, it’s not often
stopped ("Awakening to a New Culture of Care").
• “If we don’t identify environmental factors or triggers fueling a person’s
behavioral expressions and we don’t take time to address them, we lose
the opportunity to ‘hear’ what the person is conveying and truly care for
them” ("Awakening to a New Culture of Care").

4. Pharmacological Treatment Use
 1 in 3 dementia patients in nursing homes receives antipsychotics, while only 1 in 7
dementia patients are prescribed the drugs outside nursing homes. (Jaffe)
Antipsychotics are prescribed for nearly 300,000 nursing home residents nationally.
(Benincasa)
 “All U. S. residents of nursing homes have specific legal rights, detailed in the nursing
home reform act of 1987. Some of the most important rights include:
 the right to be free from physical or mental abuse, corporal punishment,
involuntary seclusion, and any physical or chemical restraints imposed
for purposes of discipline or convenience and not required to treat the
resident's medical symptoms” (Benincasa).
 According to a national audit of the federal Medicare program by the Office of the
Inspector General released in 2011, more than half of the antipsychotics paid for by
the federal Medicare program in 2007 were “erroneous,” costing the program $116
million in just six months ("Awakening to a New Culture of Care")
 antipsychotics are most states’ largest Medicare and Medicaid drug expense, at a
cost of more than $4 billion nationally ("Awakening to a New Culture of Care")

5. Risks of Pharmacological Treatment
Use
 The FDA has warned that antipsychotics increase the risk of death for people with
dementia. And antipsychotics are much less effective than non-drug treatments in
controlling the symptoms of dementia (Jaffe)
 “Over the course of 12 weeks, the risk of increased mortality would be 1 to 2 percent.
But at six months, the risk of death rises to 4 to 7 percent with commonly used
antipsychotics like haloperidol, risperidone and olanzapine. It continues to rise after
that” (Jaffe)
 "We saw these as medications that were supposed to help the patient and, of
course, we gave them to them with the feeling that we were doing good," says
Shelley Matthes "but they would just stay on it. They would never be taken off for
many months or even years." (Benincasa)
 Recent work indicates that neuroleptic treatment of dementia leads to reduced well-
being and quality of life (Ballard et al, 2001) and may even accelerate cognitive
decline (Douglas et al.)
 Antipsychotics put older adults at high risk for decreased cognitive function, stroke,
pneumonia (60% higher risk) and other adverse drug events. In fact, seniors taking
antipsychotics are as much as four times more likely to experience an adverse drug
event that can lead to hospitalization or death ("Awakening to a New Culture of
Care”)

6. Non-pharmacological
Treatments

7. Caregiver Education
• The best results were the found in studies educated
caregivers on how to communicate calmly and clearly, and
to introduce hobbies or other activities for the patient… “it's
inherently patient- and caregiver-centered.” (Jaffe)
• Antipsychotic drugs were only about half as effective as the
caregiver interventions

8. (Cognitive) Behavioral Therapy
• Based on principles of conditioning and learning theory
using strategies aimed at suppressing or eliminating
challenging behaviors (Douglas et al.)
• Focuses on “the ABCs”: antecedents, behaviors and
consequences (Douglas et al.)
• Uses reinforcement strategies and routines and schedules
that reduce the behavior (Douglas et al.)
• There is evidence of successful reductions in wandering,
incontinence and other forms of stereotypical behaviors
(Douglas et al.)

9. Reality Orientation
• Reality orientation is one of the most widely used
management strategies for dealing with people with
dementia and has staff remind residents of facts about
themselves and their environment (Douglas et al.)
• “Reality orientation sessions could increase people’s verbal
orientation in comparison with untreated control groups.
However, it has also been claimed that reality orientation
can remind the participants of their deterioration found an
initial lowering of mood in those attending the sessions”
(Douglas et al.).
• Can often cause anxiety and related behaviors rather than
increasing well-being.

10. Validation Therapy
• “Repetition and retreating into the past where in fact active
strategies on the part of the affected individual to avoid
stress, boredom and loneliness,” focusing on an inner reality,
as they find the present reality too painful (Douglas et al.).
• Focuses on empathizing with the feelings behind their
confused behavior (Douglas et al.).
• Promotes contentment, results in less negative affect and
behavioral disturbance, produces positive effects and
provides the individual with insight into external reality
(Douglas et al.).

11. Ecumen AwakeningsTM
“Ecumen Awakenings™ is not a cure. It is care – very
collaborative care - that puts the person at the center while
combining the knowledge, experience and abilities of the
professional care team, physicians, pharmacists, and those
whose lives are entrusted to us, and their loved ones. It is
recognizing and empowering each person’s abilities. It is
meaningful relationships. It is non-paternalistic and non-
institutional. It is honoring the person for the individual he or she
uniquely is.”
“Awakenings discovers unmet needs that often trigger
behavioral symptoms and addresses the triggers with non-
pharmacological care techniques” ("Awakening to a New
Culture of Care").

12. Ecumen AwakeningsTM
• “Our goal was to reduce our antipsychotic use by 20 percent.
And in the first year we reduced it by 97 percent.They started
interacting," recalls Matthes, "and people who hadn't been
speaking were speaking. They came alive and awakened"
(Benincasa).
• Shelly Cornish points out a vintage chest of drawers in the far
corner. "every drawer you open," she says, "you're going to find
a treasure… People with dementia are frequently looking for
something. But they don't necessarily know what they're looking
for.” (Benincasa)
• “We want everyone to know, whether they are working in the
dining services or maintenance, that when you see something
that is, quote, ‘a behavior,’ try to figure out the rationale behind
it. And once we figure that out, we can oftentimes eliminate it
completely.” (Benincasa)

13. Aromatherapy
• “There is some evidence that aromatherapy may be
effective in helping people with dementia to relax and
that certain oils may have the potential to improve
cognition in people with Alzheimer’s disease. Research
has highlighted the potential benefits of aromatherapy,
specifically the use of lemon balm (Melissa officinalis) and
lavender oil, in the treatment of Alzheimer’s disease”
("Complementary and Alternative Therapies").
• Aromatherapy is well tolerated compared to medication.
Use is flexible depending on the individual: there are
several routes of administration such as inhalation,
bathing, massage and topical application in a cream
(Douglas et al.).

14. Bright light therapy
• “Sleep disorders and disruptive nocturnal behavior are
commonly associated with dementia and present a
significant clinical problem. These include a characteristic
pattern of sleep disturbance referred to as 'sundowning”
("Complementary and Alternative Therapies").
• A person sits in front of a light box that provides about 30
times more light than the average office light, for a set
amount of time each day. One study showed promising
effects of bright light therapy on restlessness and disturbed
sleep for people with dementia ("Complementary and
Alternative Therapies").
• “A more recent study showed that using stronger general
lighting in care homes improved cognition in people with
dementia, enhanced their sense of night and day, enabled
them to sleep better, and reduced levels of depression”
("Complementary and Alternative Therapies").

15. Alternative Sensory Treatments
• Acupuncture
• Has been shown to reduce local muscle tension, and is thought to affect the way the body reacts to
pain. A number of studies have addressed the use of acupuncture, and all report positive effects,
but better studies are needed to confirm these preliminary findings. ("Complementary and
Alternative Therapies")
• Massage
• Manipulation of the body's soft tissue by the practitioner.
• “There is much anecdotal evidence that massage can help manage symptoms associated with
dementia such as anxiety, agitation and depression, but studies have not been sufficiently rigorous
to provide solid proof” ("Complementary and Alternative Therapies").
• Music
• Music therapy uses music and other sound (such as 'white noise') to restore or improve a person's
sense of well-being ("Complementary and Alternative Therapies").
• Treatment usually involves playing music or sounds that the person enjoys for up to 30 minutes in a
quiet room, and the person is often encouraged to join in with the rhythms or sing along. If there is a
certain time of the day when the person with dementia becomes agitated, music therapy can be
scheduled just before this time ("Complementary and Alternative Therapies").
• Significant reduction in agitation, increases in levels of well-being, better social interaction and
improvements in autobiographical memory in a group of nursing home residents who regularly had
music played to them (Douglas et al.)
• Art
• Provides meaningful stimulation, important non-verbal expression, improves social interactions and
self-esteem levels (Douglas et al.)

16. Alternative Non-Sensory Treatments
• Choto-san
• Contains 11 medicinal plants
• Improves a range of symptoms in people with vascular dementia.
• Further research on this preparation seems justified. ("Complementary and Alternative Therapies”)
• Kami-umtan-to (kut)
• Contains 13 different plants
• A clinical trial found a slower decline in people with Alzheimer’s disease. ("Complementary and
Alternative Therapies”)
• Reminiscence therapy
• “Involves helping a person with dementia to relive past experiences, especially those that might be
positive and personally significant, for example family holidays and weddings” (Douglas et al.).
• Suitable for groups or individuals– very flexible
• Often uses sensory activities such as art, music, or artifacts to provide stimulation (Douglas et al.)
• There is little evidence of significant cognitive impact, but some evidence suggests improvements in
behavior, well-being, social interaction, self-care and motivation (Douglas et al.)
• Activity Therapy
• Recreation, sports, dance, drama, physical exercise (Douglas et al.)
• Reduces number of falls and improves mental health and sleep, improves mood and confidence,
reduces agitation, social engagement, non-sexual physical contact (Douglas et al.)

17. Conclusion
It is important that caregivers understand the individual’s
experience of dementia and that they employ strategies to
improve the person’s quality of life. Care staff and families are
integral to treatment strategies. While pharmacological
treatments may be convenient, they may not be helpful overall
and may in fact be detrimental to the health and well being of
the individual with dementia. Care must be person-centered
and treat the underlying issues as well as helping the individual
continue living with a high quality of life.

18. Works Cited
"Awakening to a New Culture of Care." Ecumen Awakenings. N.p., 2013. Web. 19 Apr.
2015.
Benincasa, Robert and Ina Jaffe. "This Nursing Home Calms Troubling Behavior Without
Risky Drugs." NPR. NPR, 9 Dec. 2014. Web. 19 Apr. 2015.
Colon, Elving. "Nonpharmacologic and Pharmacologic Interventions for Behavior
Symptoms in Dementia." (2007): n. pag. Med.fsu. Web. 19 Apr. 2015.
"Complementary and Alternative Therapies." Alzheimers Society. Alzheimers Society,
Dec. 2014. Web. 19 Apr. 2015.
Douglas, Simon, Ian James, and Clive Ballard. "Non-pharmacological Interventions in
Dementia.” Advances in Psychiatric Treatment 10 (2004): 171-79.
Apt.rcpsych.org. 2004. Web. 19 Apr. 2015.
Jaffe, Ina. "Behavioral Therapy Helps More Than Drugs For Dementia Patients." NPR. NPR,
5 Mar. 2015. Web. 19 Apr. 2015.