Nonpharmacological Approaches to Managing Behavioral and Psychiatric Symptoms of Dementia

Dementia is a neurological disorder characterized by cognitive degeneration and gradual progressive decline in daily function, often correlated with behavioral disturbances.¹ In 2014, dementia affected approximately 5 million people residing in the United States² and 44 million worldwide.³ The number of people affected by dementia is expected to rise to 14 million in the United States² and 135 million worldwide by the year 2050.³ Dementia is the sixth leading cause of death in the United States.⁴ The Centers for Disease Control and Prevention reports that 50.4% of people residing in nursing homes (NHs) suffered from dementia in 2014.⁵ Risk factors for dementia include age, alcohol use, atherosclerosis, diabetes, Down syndrome, genetics, hypertension, mental illness, and smoking.⁴

Dementia presents as a gradual decline in both mental and physical abilities, including the ability to verbally communicate.² This overall decline often leads to disruptive and harmful behavioral symptoms. In NHs where 67% to 78% of the population has dementia, behavioral symptoms of dementia are reportedly evident in 76% of individuals with dementia.⁶ Drouillard and colleagues⁷ estimate that more than 90% of older adults with dementia will eventually exhibit behavioral and psychiatric symptoms of dementia (BPSD) associated with disease progression. The behaviors of anxiety, agitation, aggression, wandering, and psychosis are collectively referred to as BPSD and occur in clusters.^1,2,8

Neurodegenerative changes and neuronal death are associated with dysregulation of emotions and decline in emotional control or motivation. These changes can contribute to anxiety and can manifest in emotional lability, characterized by involuntary episodes of crying, laughing, or other emotional displays.^9,10 Often, this condition in dementia can lead to additional anguish.¹¹ Anxiety also can cause agitation, which can be distressing and occurs in 40% to 60% of NH residents with dementia.¹¹ In turn, agitation can lead to aggression, characterized by verbal outbursts, shouting, combativeness, and resistive behaviors. An individual with nonaggressive agitation can appear to be acting out through wandering behaviors.⁷ Wandering is a collection of abnormalities that includes aimless walking, walking with excessive frequency, and what appear to be inappropriate attempts to leave a safe environment.¹² BPSD may present differently in each individual with dementia; thus, treatment and symptom management should be individualized.⁸

Behaviors associated with dementia can be devastating to the resident and disruptive to health care workers. However, there are techniques that can assist NH care providers in reducing or eliminating anxiety, aggression, and wandering behaviors without the use of medication, which can sometimes further complicate behaviors or lead to polypharmacy. We provide practical, evidence-based strategies for health care staff to use in NHs to successfully address behaviors associated with dementia without resorting to drugs, with the ultimate aim of improving NH care delivery and residents’ quality of life.

Understanding BPSD

The first concept to understand is that BPSD is not intentional or preconceived. Traynor and colleagues¹³ completed a literature review of 59 publications, synthesized their findings, and determined the following requisite dementia nursing core competencies for health care workers across care settings: understanding dementia, recognizing behavioral symptoms of dementia, effective communication, promoting a positive environment, therapeutic interventions, adequately responding to needs, and an ethical, person-centered care model. Care for the individual with dementia should initially focus on behavior management strategies before relying on pharmacologic aids. The care provided should be patient-centered and include the entire health care team, starting with the nursing staff.⁶ Edvardsson and colleagues¹⁴ suggest establishing a calm, caring environment and ongoing development of staff competencies regarding dementia. 

Every effort should be made to first investigate potential physiological causes of BPSD.⁶ A detailed medical history and thorough evaluation can expose treatable conditions such as urinary tract infection or delirium.⁶ They can also identify potential side effects of polypharmacy.⁶ For example, concurrently prescribing medications such as antidepressants, steroids, and anticholinergics can cause anxiety.^7,9

Pain can manifest in behavioral changes that resemble BPSD, such as resistive and anxious behaviors and aggression.¹¹ Individuals with dementia will often have difficulty articulating when they are experiencing pain.¹¹ For example, anxiety and agitation can be a sign of discomfort owing to an ill-fitting assistive device such as eyeglasses, hearing aids, or dentures; these should be checked for proper fit and effectiveness and should be replaced as necessary.¹² Tools such as the Pain Assessment in Advanced Dementia¹⁵ can be used to evaluate unreported pain. This tool is fairly simple and requires no specialized training. The tool guides nursing staff to assess the mood of the individual, verbal cues, facial expressions, and body language in order to determine whether they might be experiencing pain.¹¹

Using psychotropic medications to treat BPSD in older adults should be considered with extreme caution.^7,9 There are multiple risks of morbidity and mortality with use of psychotropic medications.^7,9 The use of short-acting anxiolytics to treat anxiety and aggressive behaviors have been shown to produce withdrawal symptoms and have greater possibility of inducing dependence.⁹ Some studies have shown a link between long-term use of anxiety medications, such as benzodiazepines, and risk of Alzheimer disease (AD).^16,17 In addition, research suggests that the use of anxiolytic drugs (eg, benzodiazepines) raises the risk of hip fracture in older adults with AD.¹⁸ Other potential side effects include respiratory insufficiency; cognitive impairments, increasing the chance of falls with injury; and irritability or restlessness.⁹ Therefore, reducing the use of psychotropic medications in older adults with dementia should remain a continued priority.^17,18

Nonpharmacologic interventions can minimize or buffer the effects of emotional and physical stress.¹⁹ This is best accomplished by establishing a daily routine, so the resident feels comfortable in their daily activities. Modifying the individual’s environment to provide safety and familiar comforting items also helps to reduce stress.¹⁹

Staff Education

Encouraging NH staff to provide more patient-centered care is an effective means of increasing their social interaction with residents with dementia, which can reduce BPSD.⁶ According to Hwang, there are five goals of care when it comes to managing dementia symptoms in older adults; individuals should experience a sense of control, safety, comfort, pleasure, and feel minimal stress.⁶ These care goals can often be met without the need for medication to control behavior, as polypharmacy is always a concern in older adults. In other words, recognizing the person as an individual and meeting their need for love, attachment, comfort, identity, occupation, and companionship can enhance self-worth and reduce BPSD.⁶

Caregivers can be educated on techniques to reduce BPSD.^6,12 Staff aiming to practice patient-centered care should observe older adults with dementia to see how they interact with their environment, try to understand how certain situations contribute to the individual’s anxiety or aggression, and then try to prevent those situations.^20,21

Behavioral Management Strategies

Many behavior management strategies, such as the ones mentioned below, can be taught and implemented. These strategies are also provided in a condensed version in Table 1 for quick reference.

Communication Techniques 

As an individual’s cognition starts to decline, basic verbal communication skills will also deteriorate.^4,22 Care providers can use certain techniques to better communicate with older adults with BPSD.²³ Communication should be provided with a smile and a positive, calm tone of voice using simple terms and slow pronunciation.^22,23 However, talking to older adults as if they were a child should be avoided. Using statements instead of questions when possible is helpful. Directions should be given in one-step increments, and NH residents should be allowed adequate time to respond to the request.²³ Older adults should also be encouraged to make simple choices.²³ For example, the nurse may ask the individual if he or she would like to wear the red shirt or the blue shirt. Offering choices like this helps maintain individuals’ sense of autonomy without confusing them with too many choices. Respecting personal autonomy, when possible, helps to reduce anxiety.²³

Redirection and Reassurance

Redirection and reassurance is an often-successful primary strategy to relieve BPSD⁶ and can be used to address wandering, anxiousness, anxiety, and agitation. Redirecting and providing reassurances to older adults allow the caregiver to guide (physically and/or mentally) them to an increased sense of safety.⁶ Reasoning will likely not change behaviors, as individuals with dementia often lose the ability to reason or follow logic.⁶ Instead, care providers should calmly acknowledge their emotion and redirect the individual using a distraction to address the behavior. Successful redirection techniques include gentle persuasion, a rest period, food and/or drink, and a change of subject.⁶ One technique that may be used for older adults with wandering behavior is the placement of a mirror in front of the exit door. He or she will see their reflection and be redirected to where they came from, reducing exit-seeking behavior.¹²

Memory Support

Providing purposeful therapeutic activities can also improve quality of life for older adults with dementia as well as reduce BPSD. A randomized controlled trial demonstrated the following benefits of reminiscence therapy: improvements in mood, self-esteem, memory, and social interaction with reductions in disorientation and anxiety.²⁴ Reminiscence therapy is a form of therapy where photographs or personal items from the past are used to trigger memories in individuals with dementia; this can improve their sense of self.²³ This technique includes talking about positive past events, such as the weddings, birthdays, and early memories like family vacations as a child.²³ Collections of these events, sometimes called memory books, have been shown to enhance communication, reduce negative symptoms, and improve overall quality of life.²⁵ Recorded audio tape stories from family members discussing happy memories, can also help to reduce anxiety, agitation, and wandering behaviors associated with dementia.⁶

Sensory Stimulation

Visual stimulation. Visual sensory stimulation can often help control anxiety and aggression by providing a comforting environment. Small, home-like, predictable environments with familiar pictures often make NH residents feel more comfortable, calm, and safe.²⁰ Allowing older adults to tend or help tend to a small vegetable or flower garden can also help decrease the anxiety associated
with dementia.²⁰ 

Auditory stimulation. Music therapy is very useful as an auditory stimulation intervention.²⁶ Studies reveal that music that is well known to the individual can be effective in decreasing anxiety related to dementia in residents in NHs.^26,27 If a resident becomes upset when a certain song is played, attempt to alleviate the trigger by not playing the song.²¹

Individuals with dementia can participate in music therapy by singing or playing an instrument, or they can be passive participants by just listening.^26,27 Music therapy provides familiar songs that can encourage use of long-term memory as well as enhance emotional well-being and reduce anxiety and aggression.^22,28 Group music therapy has been shown to be more effective in improving anxious behaviors than individual sessions.²⁶

Olfactory stimulation. Controlled clinical trials have shown promising results with daily administration of aromatherapy to improve BPSD.^29,30 Fujii and colleagues³¹ discovered improvement of sleep patterns with the use of lavender oil placed under pillows nightly in residents in LTC facilities, which could help those who tend to wander at night. A study by Lin and colleagues²⁹ revealed that residents who were exposed to an aroma diffusion of two drops of lavender and sunflower oils at bedside nightly showed a reduction in physical aggression, verbal agitation, anxiety, and wandering behaviors. In another study, researchers found that rubbing lotion with lavender, geranium, and mandarin oils into NH residents’ skin improved alertness, decreased anxiety and wandering, and improved sleep patterns.³⁰ Other beneficial aromatherapy oils include ylang ylang, patchouli, rosemary, and peppermint. When used regularly, these oils showed a decrease in anxiety and wandering exhibited by individuals with dementia.^29,30

Taste stimulation. Food can be a source of stress for older adults with dementia due to all the choices of food.³¹ By providing simple finger food choices—such as small sandwiches, fruit and cheese trays, and nutrition-packed muffins and cereal bars—this stress can be alleviated, allowing for a more pleasant dining experience.^31,32 One study showed that mealtime stressors could be reduced by allowing NH residents to make simple decisions of food choice and by diffusing their anxiety with gentle support and encouragement.³³ In addition, as dementia progresses, individuals may struggle to use silverware due to lack of coordination, which may lead to anxiety and aggressive behaviors; this could be alleviated with portable finger foods.³³

Tactile stimulation. Human touch can play an integral role in provider-individual interaction. Namaste Care techniques are based on the theory that all human beings respond to and benefit from touch.^34,35 Tactile stimulation contributes to a feeling of trust and also promotes relaxation and a sense of calm.^34,35 The types of touch can range from gently brushing a NH resident’s hair to hand massages.³⁵ Providing a hand massage connects the nursing staff with the individual in an intimate relationship.^34,36 Touch can convey attention, communication, and close contact.^34,35  Studies have shown that tactile massage can reduce anxiety and improve cognition, and caregivers have reported feeling closer to older individuals after providing the technique.^31,34,36 One way that caregivers communicate with residents is by being relaxed, smiling, and maintaining eye contact with them during interactions.²¹ Caregivers can utilize the “hand-under-hand” technique, which involves the caregiver placing their hand under the individual’s hand while providing guidance.⁶ This technique reportedly reduces stress while still providing support.⁶ Increased verbal and tactile staff interaction and increasing residents’ social interaction through group activities has been shown to be effective in reducing anxiety, aggression, and wandering behaviors.¹⁸

Allowing the older adult to stroke and interact with pets is another way that tactile stimulation is accomplished. One study showed that pet therapy could reduce agitation and anxiety among older adults with cognitive disorders.²² For example, brushing a dog’s fur can be a soothing activity and has been shown to reduce anxiety and improve individuals’ self-esteem.³⁷

Exercise

Exercise is important for maintaining physical health in all older adults,³⁸ and it should not be overlooked when it comes to helping those with BPSD. A randomized controlled trial demonstrated that individuals with dementia who participated in an exercise program twice a week for 1 year experienced an enhanced level of physical functioning and independence, as well as improvement in their mood; this resulted in a reduction of anxiety and agitation.³⁸ Exercise programs can consist of multiple components such as daily sessions of aerobic, balance, resistance, and walking. Exercises can be done in a chair or standing. Wong and Leland³⁹ evaluated exercise programs in a NH and found a reduction in anxiety, agitation, and wandering behaviors associated with dementia.³⁹

Conclusion

Older adults suffering from dementia can experience both nonpsychotic and psychotic behaviors including anxiety, agitation, aggression, wandering, and psychosis.⁸ There are many strategies that staff who work in NHs can use to successfully address BPSD before or without resorting to pharmacologic aids. Recognizing the NH resident as an individual and providing a safe and stress-free environment are the first steps in successful behavior management. 

References

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