Nonpharmacologic Treatment of Neuropsychiatric Symptoms of Dementia

DICE approach

• Describe – further characterize the behavior (remember, all behavior is a communication), contextualize, determine safety risk
• Investigate –
  • consider patient (physical discomfort – pain, fatigue, hunger/thirst, medication side-effects); emotional symptoms, stress)
  • consider caregiver
  • consider environmental contributions (changes in routine; over- or understimulation)
• Create – address pain, limit distractions
  • Keep things simple, ask or say one thing at a time
  • Have a daily routine, so they can expect certain things will happen
  • Reassure that he or she is safe and you’re there to help
  • Focus on his or her feelings rather than words “you seem worried”
  • Don’t try to argue or reason
• Evaluate

Interventions at the level of the patient (Kales, Gitlin, and Lyketsos, 2015)

• Activities: activities in care homes reduce level of agitation at the time of intervention, but there’s no clear long-term effect (Livingston et al, 2014)
• Reminiscence therapy (discussion of previous life experiences)
• Validation therapy (supportive)
• Simulated presence therapy (playing audio files of family members’ voices)
• Sensory interventions (massage, Snoezelen therapy, multisensory interventions of tactile, light, and auditory stimulation): improvement in agitation (Livingston et al, 2014)
• Cognitive training and rehabilitation
• Music therapy: RCTs in care homes, generally warming up with a well-known song, listening to, and participating in music, found it was effective for reducing agitation immediately, though little evidence of longer-term effect (Livingston et al, 2014)

Interventions at the level of the caregiver: (Kales, Gitlin, and Lyketsos, 2015)

• Caregiver support programs (including education and training)
  • Encourage training staff to see and treat patients as individuals rather than being task-focused (Livingston et al, 2014)
  • Person-centered care was found to reduce agitation (Chenoweth et al, 2009), examples included teaching staff various holistic concepts such as:
    • behavior is a form of communication
    • feelings persist despite cognitive impairment
    • acknowledging feelings during interactions
    • developing personalized approaches to patients’ needs

Environmental approach (Kales, Gitlin, and Lyketsos, 2015)

• Reduction of environmental triggers (as dementia progresses, stress may be caused by changes in routine or environment, competing or misleading stimuli, lack of stimulation, etc.)
• Removal of potential safety hazards (restrict access to chemicals or sharp objects; additional barriers to prevent patient from easily leaving the home)

References

Chenoweth, L. et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol. 8, 317–325 (2009). https://pubmed.ncbi.nlm.nih.gov/19282246/

Kales, H. C., Gitlin, L. N. & Lyketsos, C. G. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350, h369–h369 (2015). https://pubmed.ncbi.nlm.nih.gov/25731881/

Livingston, G. et al. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. Br. J. Psychiatry 205, 436–442 (2014). https://pubmed.ncbi.nlm.nih.gov/25452601/