Special ArticlesNonpharmacologic Interventions for Inappropriate Behaviors in Dementia: A Review, Summary, and Critique
Section snippets
The Underlying Assumptions and the Importance of Nonpharmacologic Interventions
In order to understand the rationale for the different nonpharmacologic interventions utilized in the research literature, it is important to understand the theoretical framework they embrace in conceptualizing inappropriate behaviors in dementia. Three theoretical models have generally been applied: 1) the “unmet needs” model; 2) a behavioral/learning model; and 3) an environmental vulnerability/reduced stress-threshold model.
Advantages of Nonpharmacologic Interventions
The reasons for using a nonpharmacologic interventions approach to treating inappropriate behaviors in dementia include the following: 1) it aims at addressing the psychosocial/environmental underlying reason for the behavior, as documented in previous research; 2) it avoids the limitations of pharmacological interventions, namely, adverse side effects, drug–drug interactions, and limited efficacy;5, 6 and 3) when medication is efficacious, it may mask the actual need by eliminating the
Methods
Literature searches were conducted on PsycLIT, MEDLINE, and a nursing subset of MEDLINE. Articles were chosen that fulfilled the following criteria: 1) published as an article in a scientific book or journal (i.e., excluding presentations, abstracts, and reports); 2) participants were at least 60 years old and suffered from dementia or cognitive impairment; and 3) a measure of the behavior or of change was obtained.
The articles were organized by type of intervention. The categorization is based
The Nature of the Interventions: The Interconnections Between Domains of Functioning
Nonpharmacologic interventions address a wide range of underlying problems: hearing problems, sleep difficulties (light therapy), communication problems, inactivity, and loneliness. These difficulties in life experience are closely interlinked among themselves. The approach to reducing inappropriate behavior in dementia is therefore identical to addressing those difficulties and improving quality of life for this population. As such, these interventions may provide an initial guide to a needed
RECOMMENDATIONS: FUTURE DIRECTIONS
The results of the literature review show that many nonpharmacologic interventions show promise for treating inappropriate behaviors in dementia. The field needs to be expanded in a number of ways in order to have clinical usefulness. There is a need to address 1) the issue of individualization and proper selection of treatment: Which interventions are appropriate for which persons manifesting which behaviors? When is the goal enhanced stimulation and social contact, and when is it relaxation?
References (120)
Caring for people with Alzheimer's disease using the conceptual model of progressively lowered stress threshold in the clinical setting
Nurs Clin North Am
(1994)- et al.
Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment
Arch Psychiatr Nurs
(1994) - et al.
Effects of individualized music on confused and agitated elderly patients
Arch Psychiatr Nurs
(1993) Evaluation of a clinical intervention for wanderers on a geriatric nursing unit
Arch Psychiatr Nurs
(1997)- et al.
Indirect bright light improves circadian rest-activity rhythm disturbances in demented patients
Biol Psychiatry
(1997) - et al.
Self-identity in older persons suffering from dementia: preliminary results
Soc Sci Med
(2000) - et al.
The effect of expressive physical touch on patients with dementia
Int J Nurs Stud
(1999) - et al.
Efficacy of hand massage in decreasing agitation behaviors associated with care activities in persons with dementia
Geriatric Nursing
(1995) - et al.
Simulated Presence Therapy: using selected memories to manage problem behaviors in Alzheimer's disease patients
Geriatr Nurs
(1995) - et al.
Behavioral analysis and nursing interventions for reducing disruptive behaviors of patients with dementia
Appl Nurs Res
(1995)
Evaluation of a clinical intervention for wanderers on a geriatric nursing unit
Arch Psychiatr Nurs
Effect of bright-light treatment on agitated behavior in institutionalized elderly subjects
Psychiatry Res
Agitated behaviors in the elderly, I: a conceptual review
J Am Geriatr Soc
Agitation among elderly persons at adult day-care centers: the experiences of relatives and staff members
Int Psychogeriatr
Progressively lowered stress threshold: a conceptual model for care of adults with Alzheimer's disease
Arch Psychiatr Nurs
Withdrawal of haloperidol, thioridazine, and lorazepam in the nursing home
Arch Intern Med
Meta-analysis of controlled pharmacologic trials
Int Psychogeriatr
Geriatric patients who improve in token economy and general milieu treatment programs: a multivariate analysis
J Consult Clin Psychol
A randomized trial of dementia care in nursing homes
J Am Geriatr Soc
Use of music to decrease aggressive behaviors in people with dementia
J Gerontol Nurs
The effects of music on bathing cooperation for residents with dementia
J Music Ther
Quiet music: an intervention for mealtime agitation
J Gerontol Nurs
Influence of dinner music on food intake and symptoms common in dementia
Scand J Caring Sci
Management of verbally disruptive behaviors in nursing home residents
J Gerontol Med Sci
Effects of individualized vs. classical “relaxation” music on the frequency of agitation in elderly persons with Alzheimer's disease and related disorders
Int Psychogeriatr
Effects of calming music on the level of agitation in cognitively impaired nursing home residents
Am J Alzheimer Care Rel Disord Res
The effects of music therapy intervention on agitation behaviors of Alzheimer's disease patients
J Music Ther
Environmental “white noise”: an intervention for verbally agitated nursing home residents
J Gerontol Psychol Sci Soc Sci
Managing nocturnal wandering behavior
J Gerontol Nurs
Sensory stimulation and the treatment of senile dementia
Med J Aust
A pet therapy intervention with geriatric psychiatry inpatients
Am J Occup Ther
Using a therapy dog to alleviate the agitation and desocialization of people with Alzheimer's disease
J Psychosoc Nurs Ment Health Serv
Association with companion animals and the expression of noncognitive symptoms in Alzheimer's patients
J Nerv Ment Dis
An empirical test of language-relevant interventions for dementia
Int Psychogeriatr
Reality orientation and dementia: a controlled trial of two approaches
Br J Psychiatry
A combination of operant and cognitive therapy with geriatric patients
Int J Behav Geriatr
Calming aggressive reactions: a preventive program
J Gerontol Nurs
An in-service workshop for nursing personnel on the management of catastrophic reactions in dementia victims
Clin Gerontologist
Educating nursing assistants to communicate more effectively with nursing home residents with dementia
Gerontologist
Effect of an abilities-focused program of morning care on residents who have dementia and on caregivers
J Am Gerontol Soc
Management of problematic behavioral symptoms associated with dementia: a cognitive developmental approach
Aging Clin Exp Res
Evaluation of an in-service training program on dementia and wandering
J Gerontol Nurs
The nursing assistant's use of recreational interventions for behavioral management of residents with Alzheimer's disease
Am J Alzheimers Dis Other Demen
Effect of a program of diverse activities on disturbed behavior in three severely demented patients
Int Psychogeriatr
Visits to an outdoor garden: impact on behavior and mood of nursing home residents who pace
Confined to barracks: the effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit
Am J Alzheimers Dis Other Demen
Pertinent autonomy for residents with dementias: modification of the physical environment to enhance independence
Am J Alzheimer Dis Rel Dis Res
The effect of natural environments upon agitation and aggression in late-stage dementia patients
Am J Alzheimers Dis Other Demen
The effects of an enhanced environment on nursing home residents who pace
Gerontologist
Effects of a “quiet week” intervention on behavior in an Alzheimer boarding home
Am J Alzheimer Care Rel Dis Res
Cited by (489)
Histone deacetylase 1 regulates haloperidol-induced motor side effects in aged mice
2023, Behavioural Brain ResearchEditorial for advances in human-centred dementia technology
2023, International Journal of Human Computer StudiesNAbiximols Clinical Translation To the treatment of Pain and Agitation In Severe Dementia (NACTOPAISD): Clinical trial protocol
2022, Biomedicine and PharmacotherapyStrategies used by care home staff to manage behaviour that challenges in dementia: A systematic review of qualitative studies
2022, International Journal of Nursing StudiesCitation Excerpt :“Being there, dealing with it, doing it, is the best training” (care assistant) (Rapaport et al., 2018). The environmental vulnerability/reduced stress-threshold model assumes that people with dementia have a lower threshold for tolerating stress associated with environmental stimuli, resulting in behaviour that challenges (Cohen-Mansfield, 2001). Indeed, staff acknowledged that environmental factors may trigger behaviour that challenges, thereby providing support for the environmental vulnerability/reduced stress-threshold model.
“Bring me sunshine, bring me (physical) strength”: The case of dementia. Designing and implementing a virtual reality system for physical training during the COVID-19 pandemic
2022, International Journal of Human Computer Studies