Non-Pharmacological Approaches to Address Behaviors

This section of the Toolkit contains a literature review on non-pharmacological approaches (NPA) most effective in reducing the behavioral and psychological symptoms of distress (BPSD) exhibited by persons with dementia residing in nursing homes. NPA are the first-line therapy for responding to BPSD due to the high risks and limited effectiveness of antipsychotic medications for treating these symptoms. As a result, there is an urgent need to equip nursing home providers with readily accessible tools for identifying and implementing NPA.

After presenting information that will help staff understand BPSD, practical guidance for providers, lessons learned from the field (i.e., direct care staff focus group findings), and descriptions of clinical decision support approaches are provided.

Realizing the challenges nursing home providers encounter when faced with the realities of responding to BPSD in a resource-challenged environment, experts are increasingly calling attention to the need to address both the feasibility and efficacy of NPA in nursing home settings. Among the common resource challenges faced by nursing home providers are limited access to staff with advanced training in dementia care, limited resources and high rates of turnover. The goal of this guide is to assist nursing home providers in identifying the optimal evidence-feasibility fit for their residents and facility. Feasibility was defined here using Seitz and colleagues’ guidelines[1]: high-feasibility approaches require fewer resources, lower-cost supplies, less complex activities, minimal staff training, and less need for additional personnel and less specialized personnel.

To help providers overcome some of these challenges, two tables are provided: Table 1 presents a succinct review of the evidence for different NPA; Table 2 offers practical guidance for providers, integrating both the efficacy and feasibility of different NPA. While the evidence in support of NPA may seem weak when assessed using criteria that conform to the elements of randomized clinical trials, many of these criteria (blinding and random assignment, for example) are not possible in studies that test efficacy given the nature of NPA. The evidence in Table 1 should be interpreted in light of the limitations of available systematic reviews of NPA where the selection of studies for inclusion may be very small and the criteria for assessment more appropriate for pharmaceutical trials.

Practical Guidance for Nursing Home Providers

In addition to being effective, NPA should also be feasible. Nursing homes have multiple barriers to implementing practice change.[7]To assist nursing home providers in choosing which NPA to implement, Table 2 lists specific NPA identified during a review of extant evidence and includes those approaches that demonstrated both efficacy and feasibility. An approach was considered to be more feasible if it required fewer resources, lower-cost supplies, less complex activities, minimal staff training, and less need for additional or specialized personnel. In most nursing home settings, feasibility is centrally important for the sustainability of a given approach.

Critical considerations in implementing non pharmacologic approaches: Lessons from our focus groups with direct care providers.

Regardless of the specific NPA selected for use in addressing the resident’s BPSD, several considerations should be kept in mind.

  1. Human behaviors are a dynamic, moving target.
    All of us have good days and bad days. Fluctuations in mood and behavior are a normal part of human functioning. For persons living with dementia, these fluctuations can be even more exaggerated. In our focus groups direct care providers eloquently expressed their awareness of these fluctuations in acknowledging that sometimes it is really hard to pinpoint what may “set someone off” on any given day. If you follow all the guidance and direction provided by this toolkit, you may still be stymied on what is causing a given resident’s distress in a specific moment in time.

  2. It’s all about trial and error.
    There is no magic bullet. Selecting a given approach to trial with a given resident with BPSD is only the beginning of the process. Though this toolkit has delineated the best and most feasible evidence based approaches for you, keep in mind that any given approach follows the “one-third” rule. A given approach may work for about a third of persons immediately; while with another third it will be only moderately successful, and the final third will not respond at all. To make things even more complex, as the direct care providers noted in our discussions, an approach that works today, may not work tomorrow, or, even an hour from now. Furthermore, some approaches that are effective when implemented by one direct caregiver may not work when implemented by another. These realities have several implications:
    • Foster a mind set of “let’s try this and see what happens”
    • Always have a backup approach if a given approach is not successful
    • One trial of an approach may not be sufficient. Try again another day.
    • Interview and observe what a “successful” direct provider is doing and saying. Within his or her success lies important information that can be shared with others.

  3. Individualizing the approach to a given person is critical to success.
    Many research reviews have stressed that the more individualized or tailored an approach is, the more likely it will be that it will succeed. Direct care providers describe the process of getting to know an individual’s preferences as the secret to success in preventing or ameliorating the BPSD. They also articulate feeling hampered by knowing very little about an individual new to a facility. The flow of information from family member to direct care staff is often not a linear process, hampering the direct care workers ability to provide person centered care.

    Effective evidence-based tools are designed to help facilitate collecting and sharing this information. The first is collected upon admission via the 16 items from the MDS 3.0 Section F Customary Routine. Collecting and sharing this information with direct care staff within the first 24 to 48 hours of admission can be an effective way of closing the individualized knowledge gap. The second tool is the Preferences for Everyday Living Inventory (PELI) (see System Integration section of Toolkit).[8] The PELI is designed to provide a comprehensive overview of the daily preferences, providing more detail beyond the items included in the MDS 3.0 Section F. Recently, the MDS Section F items have been incorporated into an Advancing Excellence Campaign Person Centered Care (PCC) quality improvement tool that allows providers to track whether or not a given resident’s preferences are being honored to his or her satisfaction. This PCC tool allows providers to see “at a glance” which resident preferences are not being met. Targeting these unmet preferences is one strategy for selecting a particular approach to address that individual’s distress in experiencing BPSD.[8,9]


  4. Involve the direct care worker in the interdisciplinary care planning team.
    Interdisciplinary teams are the optimal venue for selecting a particular approach for a given resident. Too often these teams do not include the direct care worker. While logistical difficulties abound in facilitating participation by direct care workers, interdisciplinary teams ignore this critical team member to their peril. The direct care workers we talked with believed that the team was missing critical information by excluding them. They also believed that the care plan did not adequately reflect approaches that were useful to them in their daily care activities. Reflecting the centrality of including the direct care giver in the care planning team meetings, Advancing Excellence included this metric in their Person-Centered Care Quality indicator.[10]

  5. There is a need for specific approaches to acute episodes of a given behavior.
    In addition to knowing the individual preferences of each resident, direct care staff requested information on how to initially respond to acute episodes of behaviors such as hitting, spitting, or screaming. Specifically, they requested information on “what to say” and “how to react’” in the moment. For this reason a section was added on individual behaviors that lists approaches for initial responses that help de-escalate the behavior (see Specific Behaviors in the Toolkit). Staff also indicated that the best method for staff education is live demonstration or videos that depict successful approaches vs. unsuccessful approaches. They did not feel that written information or the internet were viable options for continuing education. The Education and Leadership section of the Toolkit highlights in red those educational programs that include demonstrations and videos on how to respond to acute episodes of behavior.

Review of the Evidence for Non-pharmacologic Approaches

Several different types of non-pharmacologic approaches are reflective of theoretical frameworks about the predisposing/precipitating factors and meaning of behaviors. Among these are: sensory stimulation, environmental modification, behavioral therapy, cognitive/emotion-oriented approaches, social contact (real or simulated), caregiver training/development (see Education and Leadership Development section of the Toolkit), structured activities, clinically-oriented approaches, individualized/person-centered care, and clinical decision support approaches. Findings from systematic reviews that have evaluated the evidence for these approaches are inconsistent, due in part to reviews having different criteria for inclusion of studies. A summary of the evidence for specific non-pharmacological approaches is presented in Table 1. In addition to systematic reviews, articles related to clinical-decision support were retrieved separately. Across systematic reviews the following points were highlighted:

Non-Pharmacological Approaches for BPSD

References

  1. Seitz DP, Brisbin S, Herrmann N, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long-term care: a systematic review. Journal of the American Medical Directors Association. Jul 2012;13(6):503–506 e502.
  2. Lyketsos CG, Carrillo MC, Ryan JM, et al. Neuropsychiatric symptoms in Alzheimer’s disease. Alzheimer's & Dementia. 2011;7(5):532–539.
  3. Lyketsos CG, Carrillo MC, Ryan JM, et al. Neuropsychiatric symptoms in Alzheimer's disease. Alzheimer's & Dementia. Sep 2011;7(5):532–539.
  4. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA : the journal of the American Medical Association. Oct 19 2005;294(15):1934–1943.
  5. Husebo BS, Ballard C, Aarsland D. Pain treatment of agitation in patients with dementia: a systematic review. Int J Geriatr Psychiatry. Oct 2011;26(10):1012–1018.
  6. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. Bmj. July 17, 2011 2011;343.
  7. Siders C, Nelson A, Brown LM, et al. Evidence for implementing non-pharmacological interventions for wandering. Rehabilitation Nursing. 2004;29(6):195–206.
  8. Van Haitsma K, Curyto K, Spector A, et al. The Preferences for Everyday Living Inventory: Scale Development and description of psychosocial preferences responses in community-dwelling elders. Gerontologist. Aug 30 2012.
  9. Van Haitsma K. Resident choice made easier. Provider (Washington, DC). 2013;39(2):37.
  10. Advancing Excellence Campaign in America's Nursing Homes: Person Centered Care Quality Indicator.
    http://www.nhqualitycampaign.org/star_index.aspx?controls=personcenteredcareexploregoal
  11. Kong E, Evans LK, Guevara JP. Nonpharmacological intervention for agitation in dementia: a systematic review and meta-analysis. Aging Ment Health. 2009;13(4):512–520.
  12. Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. Am J Geriatr Psychiatry. Fall 2001;9(4):361–381.
  13. O'Connor D, Ames D, Gardner B, King MT. Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards. International Psychogeriatrics. 2009;21(225).
  14. Ayalon L, Gum A, Feliciano L, Arean P. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: A systematic review. Arch Intern Med. November 13, 2006 2006;166(20):2182–2188.
  15. O'Neil M, Freeman M, Christensen V, Telerant A, Addleman A, Kansagara D. Non-pharmacological interventions for behavioral symptoms of dementia: a systematic review of evidence. In: Affairs V, ed. Washington DC: Evidence-based Synthesis Program; 2011.
  16. Brodaty H, Arasaratnam C. Meta-Analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. American Journal of Psychiatry. 2012;169(9):946–953.
  17. Cohen-Mansfield J, Marx M, Freedman L, et al. The comprehensive process model of engagement. Am J Geriatr Psychiatry. Oct 2011;19(10):859–870.
  18. Cohen-Mansfield J. Turnover among nursing home staff. A review. Nurs Manage. May 1997;28(5):59–62, 64.
  19. Cohen-Mansfield J, Marx M, Dakheel-Ali M, Regier N, Thein K. Can persons with dementia be engaged with stimuli? Am J Geriatr Psychiatry. Apr 2010;18(4):351–362.
  20. Cohen-Mansfield J, Marx M, Regier N, Dakheel-Ali M. The impact of personal characteristics on engagement in nursing home residents with dementia. Int J Geriatr Psychiatry. 2009;24(7):755–763.
  21. Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M, Freedman L. Efficacy of nonpharmacologic interventions for agitation in advanced dementia: a randomized, placebo-controlled trial. J Clin Psychiatry. Sep 2012;73(9):1255–1261.
  22. Kovach CR, Kelber ST, Simpson M, Wells T. Behaviors of nursing home residents with dementia: examining nurse responses. J Gerontol Nurs. Jun 2006;32(6):13–21.
  23. Sloane P, Hoeffer B, Mitchell C, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J Am Geriatr Soc. Nov 2004;52(11):1795–1804.
  24. Jablonski RA, Kolanowski A, Therrien B, Mahoney EK, Kassab C, Leslie DL. Reducing care-resistant behaviors during oral hygiene in persons with dementia. BMC oral health. 2011;11:30.
  25. Jablonski RA, Therrien B, Mahoney EK, Kolanowski A, Gabello M, Brock A. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Special care in dentistry : official publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry. May–Jun 2011;31(3):77–87.
  26. Kovach C, Logan B, Noonan P, et al. Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia. American Journal of Alzheimer's Disease and Other Dementias. May/June 2006 2006;21(3):147–155.
  27. Kovach C, Simpson M, Joosse L, et al. Comparison of the effectiveness of two protocols for treating nursing home residents with advanced dementia. Research in Gerontological Nursing. 2012;5(4):251–263.
  28. Kales, H., Gitlin, L., & Lyketsos, C. Non-pharmacological management of behavioral symptoms in dementia. JAMA. 2012;308(19): 2020-9.
  29. Cabrera, E., Sutcliffe, C., Verbeek, H., Saks, K., Soto-Martin, M., Meyer, G., . . . Zabalegui, A. (2015). Non-pharmacological interventions as a best practice strategy in people with dementia living in nursing homes. A systematic review. European Geriatric Medicine, 6(2), 134-150. doi: 10.1016/j.eurger.2014.06.003
  30. Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., . . . Cooper, C. (2014). Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. Br J Psychiatry, 205(6), 436-442. doi: 10.1192/bjp.bp.113.141119
  31. Sanchez, A., Millan-Calenti, J. C., Lorenzo-Lopez, L., & Maseda, A. (2013). Multisensory stimulation for people with dementia: a review of the literature. Am J Alzheimers Dis Other Demen, 28(1), 7-14. doi: 10.1177/1533317512466693
  32. Burgio, L., Scilley, K. J., Hardin, M., Hsu, C., & Yancey, J. (1996). Environmental "White Noise": An Intervention for Verbally Agitated Nursing Home Residents. Journal of Gerontology: Psychological Sciences, 51B(6), 364-373.
  33. Hanford, N., & Figueiro, M. (2013). Light therapy and Alzheimer's disease and related dementia: past, present, and future. J Alzheimers Dis, 33(4), 913-922. doi: 10.3233/JAD-2012-121645
  34. Moyle, W., Murfield, J. E., O'Dwyer, S., & Van Wyk, S. (2013). The effect of massage on agitated behaviours in older people with dementia: a literature review. J Clin Nurs, 22(5-6), 601-610. doi: 10.1111/j.1365-2702.2012.04234.x
  35. Forrester, L., Maayan, N., Orrell, M., Spector, A., Buchan, L., & Soares-Weiser, K. (2014). Aromatherapy for dementia (Review). The Cochrane Reviews.
  36. Fu, C., Moyle, W., & Cooke, M. (2013). A randomised controlled trial of the use of aromatherapy and hand massage to reduce disrptive behavior in people with dementia. BMC Complementary and Alternative Medicine, 13(165), 1-9.
  37. Bernabei, V., De Ronchi, D., La Ferla, T., Moretti, F., Tonelli, L., Ferrari, B., . . . Atti, A. R. (2013). Animal-assisted interventions for elderly patients affected by dementia or psychiatric disorders: a review. J Psychiatr Res, 47(6), 762-773. doi: 10.1016/j.jpsychires.2012.12.014
  38. O'Neil, M., Freeman, M., Christensen, V., Telerant, A., Addleman, A., & Kansagara, D. (2011). Non-pharmacological Interventions for Behavioral Symptoms of Dementia: A Systematic Review of the Evidence.: VA-ESP Project #05-225.
  39. Zetteler, J. (2008). Effectiveness of simulated presence therapy for individuals with dementia: a systematic review and meta-analysis. Aging Ment Health, 12(6), 779-785. doi: 10.1080/13607860802380631
  40. Achterberg, W. P., Pieper, M. J., van Dalen-Kok, A. H., de Waal, M. W., Husebo, B. S., Lautenbacher, S., . . . Corbett, A. (2013). Pain management in patients with dementia. Clin Interv Aging, 8, 1471-1482. doi: 10.2147/CIA.S36739
  41. Bradford, A., Shrestha, S., Snow, A. L., Stanley, M. A., Wilson, N., Hersch, G., & Kunik, M. E. (2012). Managing pain to prevent aggression in people with dementia: a nonpharmacologic intervention. Am J Alzheimers Dis Other Demen, 27(1), 41-47. doi: 10.1177/1533317512439795
  42. Corbett, A., Husebo, B., Malcangio, M., Staniland, A., Cohen-Mansfield, J., Aarsland, D., & Ballard, C. (2012). Assessment and treatment of pain in people with dementia. Nat Rev Neurol, 8(5), 264-274. doi: 10.1038/nrneurol.2012.53
  43. Corbett, A., Husebo, B. S., Achterberg, W. P., Aarsland, D., Erdal, A., & Flo, E. (2014). The importance of pain management in older people with dementia. Br Med Bull, 111(1), 139-148. doi: 10.1093/bmb/ldu023
  44. Konno, R., Kang, H. S., & Makimoto, K. (2014). A best-evidence review of intervention studies for minimizing resistance-to-care behaviours for older adults with dementia in nursing homes. J Adv Nurs, 70(10), 2167-2180. doi: 10.1111/jan.12432
  45. Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J. K., & Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: Randomized controlled study. The Gerontologist, 54(4), 634-650.
  46. Chang, Y. S., Chu, H., Yang, C. Y., Tsai, J. C., Chung, M. H., Liao, Y. M., ... & Chou, K. R. (2015). The efficacy of music therapy for people with dementia: A meta‐analysis of randomised controlled trials. Journal of clinical nursing.
  47. Petrovsky, D., Cacchione, P. Z., & George, M. (2015). Review of the effect of music interventions on symptoms of anxiety and depression in older adults with mild dementia. International Psychogeriatrics, 1-10.
  48. Livingston G, Kelly L, Lewis-Holmes E, et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technology Assessments 2014; 18(39): 1-226, v-vi. doi: 10.3310/hta18390.