Nonpharmacologic Interventions for Inappropriate Behaviors in Dementia: A Review, Summary, and Critique

doi:10.1097/00019442-200111000-00005

The American Journal of Geriatric Psychiatry

Volume 9, Issue 4, Autumn 2001, Pages 361-381

https://doi.org/10.1097/00019442-200111000-00005 Get rights and content

Inappropriate behaviors are very common in dementia and impose an enormous toll both emotionally and financially. Three main psychosocial theoretical models have generally been utilized to explain inappropriate behaviors in dementia: the “unmet needs” model, a behavioral/learning model, and an environmental vulnerability/reduced stress-threshold model. A literature search yielded 83 nonpharmacological intervention studies, which utilized the following categories of interventions: sensory, social contact (real or simulated), behavior therapy, staff training, structured activities, environmental interventions, medical/nursing care interventions, and combination therapies. The majority are reported to have a positive, albeit not always significant, impact. Better matching of the available interventions to patients' needs and capabilities may result in greater benefits to patients and their caregivers.

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)

GR Hall
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)
J Goddaer et al.
Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment
Arch Psychiatr Nurs
(1994)
LA Gerdner et al.
Effects of individualized music on confused and agitated elderly patients
Arch Psychiatr Nurs
(1993)
SK Holmberg
Evaluation of a clinical intervention for wanderers on a geriatric nursing unit
Arch Psychiatr Nurs
(1997)
E Van Someren et al.
Indirect bright light improves circadian rest-activity rhythm disturbances in demented patients
Biol Psychiatry
(1997)
J Cohen-Mansfield et al.
Self-identity in older persons suffering from dementia: preliminary results
Soc Sci Med
(2000)
EJ Kim et al.
The effect of expressive physical touch on patients with dementia
Int J Nurs Stud
(1999)
M Snyder et al.
Efficacy of hand massage in decreasing agitation behaviors associated with care activities in persons with dementia
Geriatric Nursing
(1995)
P Woods et al.
Simulated Presence Therapy: using selected memories to manage problem behaviors in Alzheimer's disease patients
Geriatr Nurs
(1995)
S Boehm et al.
Behavioral analysis and nursing interventions for reducing disruptive behaviors of patients with dementia
Appl Nurs Res
(1995)

SK Holmberg

Evaluation of a clinical intervention for wanderers on a geriatric nursing unit

Arch Psychiatr Nurs

(1997)

BB Lovell et al.

Effect of bright-light treatment on agitated behavior in institutionalized elderly subjects

Psychiatry Res

(1995)

J Cohen-Mansfield et al.

Agitated behaviors in the elderly, I: a conceptual review

J Am Geriatr Soc

(1986)

J Cohen-Mansfield et al.

Agitation among elderly persons at adult day-care centers: the experiences of relatives and staff members

Int Psychogeriatr

(1995)

GR Hall et al.

Progressively lowered stress threshold: a conceptual model for care of adults with Alzheimer's disease

Arch Psychiatr Nurs

(1987)

J Cohen-Mansfield et al.

Withdrawal of haloperidol, thioridazine, and lorazepam in the nursing home

Arch Intern Med

(1999)

LS Schneider

Meta-analysis of controlled pharmacologic trials

Int Psychogeriatr

(1996)

BL Mishara

Geriatric patients who improve in token economy and general milieu treatment programs: a multivariate analysis

J Consult Clin Psychol

(1978)

BW Rovner et al.

A randomized trial of dementia care in nursing homes

J Am Geriatr Soc

(1996)

ME Clark et al.

Use of music to decrease aggressive behaviors in people with dementia

J Gerontol Nurs

(1998)

DW Thomas et al.

The effects of music on bathing cooperation for residents with dementia

J Music Ther

(1997)

A Denney

Quiet music: an intervention for mealtime agitation

J Gerontol Nurs

(1997)

H Ragneskog et al.

Influence of dinner music on food intake and symptoms common in dementia

Scand J Caring Sci

(1996)

J Cohen-Mansfield et al.

Management of verbally disruptive behaviors in nursing home residents

J Gerontol Med Sci

(1997)

LA Gerdner

Effects of individualized vs. classical “relaxation” music on the frequency of agitation in elderly persons with Alzheimer's disease and related disorders

Int Psychogeriatr

(2000)

PA Tabloski et al.

Effects of calming music on the level of agitation in cognitively impaired nursing home residents

Am J Alzheimer Care Rel Disord Res

(1995)

M Brotons et al.

The effects of music therapy intervention on agitation behaviors of Alzheimer's disease patients

J Music Ther

(1996)

L Burgio et al.

Environmental “white noise”: an intervention for verbally agitated nursing home residents

J Gerontol Psychol Sci Soc Sci

(1996)

SH Young et al.

Managing nocturnal wandering behavior

J Gerontol Nurs

(1988)

H Bower

Sensory stimulation and the treatment of senile dementia

Med J Aust

(1967)

MH Zisselman et al.

A pet therapy intervention with geriatric psychiatry inpatients

Am J Occup Ther

(1996)

M Churchill et al.

Using a therapy dog to alleviate the agitation and desocialization of people with Alzheimer's disease

J Psychosoc Nurs Ment Health Serv

(1999)

C Fritz et al.

Association with companion animals and the expression of noncognitive symptoms in Alzheimer's patients

J Nerv Ment Dis

(1995)

S Runci et al.

An empirical test of language-relevant interventions for dementia

Int Psychogeriatr

(1999)

IG Hanley et al.

Reality orientation and dementia: a controlled trial of two approaches

Br J Psychiatry

(1981)

RA Hussian

A combination of operant and cognitive therapy with geriatric patients

Int J Behav Geriatr

(1983)

JC Mentes et al.

Calming aggressive reactions: a preventive program

J Gerontol Nurs

(1989)

DP Williams et al.

An in-service workshop for nursing personnel on the management of catastrophic reactions in dementia victims

Clin Gerontologist

(1994)

P McCallion et al.

Educating nursing assistants to communicate more effectively with nursing home residents with dementia

Gerontologist

(1999)

DL Wells et al.

Effect of an abilities-focused program of morning care on residents who have dementia and on caregivers

J Am Gerontol Soc

(2000)

MA Matteson et al.

Management of problematic behavioral symptoms associated with dementia: a cognitive developmental approach

Aging Clin Exp Res

(1997)

J Cohen-Mansfield et al.

Evaluation of an in-service training program on dementia and wandering

J Gerontol Nurs

(1997)

Z Aronstein et al.

The nursing assistant's use of recreational interventions for behavioral management of residents with Alzheimer's disease

Am J Alzheimers Dis Other Demen

(1996)

RC Sival et al.

Effect of a program of diverse activities on disturbed behavior in three severely demented patients

Int Psychogeriatr

(1997)

J Cohen-Mansfield et al.

Visits to an outdoor garden: impact on behavior and mood of nursing home residents who pace

BG McMinn et al.

Confined to barracks: the effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit

Am J Alzheimers Dis Other Demen

(2000)

KH Namazi et al.

Pertinent autonomy for residents with dementias: modification of the physical environment to enhance independence

Am J Alzheimer Dis Rel Dis Res

(1992)

A Whall et al.

The effect of natural environments upon agitation and aggression in late-stage dementia patients

Am J Alzheimers Dis Other Demen

(1997)

J Cohen-Mansfield et al.

The effects of an enhanced environment on nursing home residents who pace

Gerontologist

(1998)

DL Meyer et al.

Effects of a “quiet week” intervention on behavior in an Alzheimer boarding home

Am J Alzheimer Care Rel Dis Res

(1992)

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The behavioral and psychological symptoms of dementia (BPSD) are experienced by up to 90% of patients with dementia throughout dementia. This study aims to investigate the effect of aromatherapy on agitation in patients with dementia in the community. This prospective cohort study was conducted at a single day-care center for patients with dementia located in northern Taiwan with 2-week and 4-week follow-ups, comparing the severity of agitation between 3 measure points as the primary outcome. The aromatherapy was performed over 5 consecutive days for 4 weeks. Throughout the four-week observation were analyzed by GEE. Significant differences were found in the Chinese version of Cohen-Mansfield Agitation Inventory (CCMAI) total agitation score (ß=-3.622, p=0.037) and physically non-aggressive behavior subscale (ß=-4.005, p=0.004) between aromatherapy group and control group. The severity of dementia-related agitation, especially the severity of physically non-aggressive behavior in demented patients, could be significantly reduced by a four-week intervention of aromatherapy.
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Citation 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.
Psychotropic drugs are often prescribed to manage behaviour that challenges in care home residents with dementia but contravene guidelines as evidence shows their use increases the risk of strokes and death. Therefore, a review is needed that conceptualises understanding of the pharmacological and non-pharmacological strategies implemented by care home staff to manage behaviour that challenges in dementia and the factors that influence decision-making. This knowledge is important to develop dementia guidelines to implement a sustainable non-pharmacological approach to support residents with behaviour that challenges.
To review qualitative studies to synthesise understanding of strategies implemented by care home staff to manage behaviour that challenges in dementia.
This systematic review involved a synthesis of qualitative data (PROSPERO protocol registration CRD42020165948). Searches of three electronic databases, PubMed, PsycINFO and CINAHL were conducted from inception until July 2021, supplemented by grey literature searches. Studies were included if they used qualitative methods and explored how care home staff respond to behaviour that challenges; data exploring other aspects of dementia care were excluded. Study quality was assessed using the Critical Appraisal Skills Programme checklist. Thematic synthesis was used to conceptualise understanding of the strategies implemented by care home staff to manage behaviour that challenges in dementia.
In total 1151 records were identified of which 34 studies were included in the review. Three themes emerged, ‘Putting out the fires’, refers to reactive strategies, implemented by staff to quell behaviour that challenges. However, if these strategies fail, staff may resort to pharmacological approaches for convenience to suppress these behaviours. The theme ‘Personhood, human rights and respect’ highlights the need for people with dementia to feel valued and useful by engaging residents in meaningful activities. Furthermore, the theme “Person focused approach – A paradigm shift” reflects changes in culture, required to implement non-pharmacological strategies to behaviour management these include staff training, collaboration and equitable decision-making.
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Special ArticlesNonpharmacologic Interventions for Inappropriate Behaviors in Dementia: A Review, Summary, and Critique

Section snippets

The Underlying Assumptions and the Importance of Nonpharmacologic Interventions

Advantages of Nonpharmacologic Interventions

Methods

The Nature of the Interventions: The Interconnections Between Domains of Functioning

RECOMMENDATIONS: FUTURE DIRECTIONS

Nurs Clin North Am

Arch Psychiatr Nurs

Arch Psychiatr Nurs

Arch Psychiatr Nurs

Biol Psychiatry

Soc Sci Med

Int J Nurs Stud

Geriatric Nursing

Geriatr Nurs

Appl Nurs Res

Arch Psychiatr Nurs

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

Special Articles
Nonpharmacologic Interventions for Inappropriate Behaviors in Dementia: A Review, Summary, and Critique