Current Treatment Options in Neurology (2013) 15:765785

DOI 10.1007/s11940-013-0257-2

DEMENTIA (E MCDADE, SECTION EDITOR)

Nonpharmacologic Treatment
of Behavioral Disorders
in Dementia
Jiska Cohen-Mansfield, PhD1,2,3
Address
1
Department of Health Promotion, School of Public Health, Sackler Faculty of
Medicine, Tel-Aviv University, Ramat Aviv, P.O.B. 39040, Tel-Aviv 69978, Israel
2
Herczeg Institute on Aging, Tel-Aviv University, Tel-Aviv, Israel
3
Minerva Center for the Interdisciplinary Study of End of Life, Tel-Aviv University,
Tel-Aviv, Israel
Email: jiska@post.tau.ac.il

Published online: 18 October 2013

* Springer Science+Business Media New York 2013

Keywords Dementia I Behavior problems I Behavioral disorders

treatment I Sensory interventions I Massage I Aromatherapy

Agitation

Treatment

Nonpharmacologic

Opinion statement
Dementia symptoms are often complicated by behavioral disorders such as repetitive
verbalizations, aggressive behavior, and pacing. In clinical practice, the most common responses to behavioral disorders are pharmacologic, mostly using antipsychotic medication, or
ignoring the behavior. However, multiple research studies support the notion that these behavioral disorders in dementia are related to unmet needs that can be addressed by
nonpharmacologic interventions. Persons with dementia present multiple unmet needs, most
commonly pain and discomfort, need of social contact and support, and need of stimulation that
alleviates boredom. A wide range of interventions that address these needs has been investigated, though the rigor of the investigations varied greatly depending on factors related to the behavioral disorder, setting, and resource limitations. In practice, the avenues to address the
unmet needs should depend on the persons abilities and preferences. Thus, nonpharmacologic
interventions that are individually tailored to the person with dementia comprise a superior response to behavioral disorders and should be at the frontline of treatment of these disorders.

Introduction
Conceptualization of behavioral disorders
in dementia
Behavioral disorders in dementia encompass a range
of observable behaviors displayed by Persons With
Dementia (PWDs) that are socially unusual or inap-

propriate. These behaviors often manifest, express, or

result from needs that are not readily identified and
do not include behaviors that address clearly identifiable bodily needs, such as running to the bathroom
and wetting oneself.

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Multiple factor analyses [1] have shown that behavioral disorders can be described along behavioral
dimensions, namely: aggressive vs nonaggressive, verbal vs physical, and frequency of display (never to
all the time). Subtypes of behavioral disorders are
therefore physically aggressive behaviors, such as hitting or kicking others; physical nonaggressive behaviors, such as pacing back and forth or handling
things inappropriately; verbally aggressive behaviors,
such as cursing; and verbal nonaggressive behaviors,
such as repetitious verbalizations. Both correlational
and longitudinal studies have shown that different subtypes of behavioral disorders are associated with different demographic and health variables. For example,
verbal manifestations, but not physical nonaggressive
behaviors, have been associated with medical problems
or pain. Aggressive behaviors tend to occur in the very
last stages of dementia [2, 3].
Conceptually, it is important to determine whether
behavioral disorders are symptoms of dementia and
therefore integral to the dementia syndrome, or alternatively, represent disease symptoms that are not specific to dementia but may stem from inappropriate
treatment of dementia and reflect symptoms of discontent or other difficulties. As will be seen in the next
section, different theoretical frameworks present different answers to this question.

Theories of behavioral disorders in dementia

Four theoretical frameworks have been proposed to
explain the etiology of behavioral disorders in dementia, including biological and genetic accounts [4], a behavioral model of the behavior as triggered and

reinforced by the environment [5], a theory of reduced

stress threshold in dementia [6], and an unmet needs
model [7]. The biological theory postulates that behavioral disorders stem from neurologic changes in
the brain or from severe organic brain deterioration
that result in behavioral disinhibition. Therefore, the
behavioral disorder is a symptom of the disease. The
behavioral theoretical framework asserts that problem
behavior is controlled by its antecedents and consequences. Antecedents operate through stimulus control
triggering a behavior, and consequences involve its reinforcement, for example, by caregivers who provide attention when the problem behavior is displayed. The third
theory asserts that the dementia process results in greater
vulnerability to the environment and a lower threshold
at which stimuli affect behavior. Therefore, normal stimulation engenders an over-reaction and disturbances that
are manifested as behavioral disorders. The unmet needs
theoretical model explains the behavioral disorders as responses to unmet needs. Given that the dementia involves a decreased ability to meet ones needs because
of communication difficulties and decreased ability to
provide for oneself and that the persons environment
often fails to detect or address the needs, persons
with dementia often experience pain/health/physical
discomfort, mental discomfort (evident in affective
states, eg,: depression, anxiety, frustration), loneliness,
and boredom.
The above theoretical models are not mutually exclusive and may pertain to different behaviors and different
persons. Yet, my research and others observations provide more support to the unmet needs model, as detailed
elsewhere [8, 9].

Treatment
Pharmacologic treatment
Drug therapy for behavioral disorders is based on the biological theoretical framework described above and therefore aims to decrease behavioral
disinhibition by changing the balance of neurotransmitters. The most
common class of drugs for pharmacologic treatment of persistent and
pervasive behavioral disorders is antipsychotic medication [1012], which
has severe side effects including increased mortality rates [10, 1315].
Consensus statements and guidelines recommend limiting the use of antipsychotics in all settings [1618]. Additional information on the use of
antipsychotics and the pharmacologic approach to treating behavioral
disorders in dementia is discussed in the accompanying topic of dementia
with Lewy bodies in this edition.

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Nonpharmacologic interventions
The goals of nonpharmacologic interventions depend on the theoretical model
used for the intervention. Most interventions aim to fulfill unmet needs,
whereas some aim to decrease the level of stimulation (eg, by playing peaceful
music) or to modify behaviors by changing contingencies or by stimulus control
(eg, by camouflaging a bothersome stimulus). Some interventions may be appropriate for multiple objectives. Regardless of the stated goal, the actual
mechanism of action is often unclear. For example, music may be provided as
sensory stimulation to combat boredom, but, if the music is presented by a
musician who provides participants with social contact, the social contact may
be the most important active ingredient of the intervention.
In a 2001 review [19] the following nomenclature for nonpharmacologic
interventions was set forth: sensory, structured activities, social contact - real
or simulated, medical/nursing care interventions, environmental interventions, behavior therapy, staff training, and combination therapies. While the
goal and the theoretical formulation may vary among interventions, general
principles can be ascertained. The first four intervention categories are based
on the unmet needs model. Specifically, sensory interventions and activities
are geared to ameliorate boredom and sensory deprivation (Fig. 1); social
contact interventions aim to alleviate loneliness (Fig. 2); and medical and
nursing interventions aim to address pain and discomfort (Fig. 3). In con-

Figure 1. Unmet needs of boredom, sensory deprivation or relaxation: examples of nonpharmacologic interventions.
(Copyright 2013, Jiska Cohen-Mansfield, PhD).

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Figure 2. Unmet need of loneliness: examples of nonpharmacologic interventions. (Copyright 2013, Jiska Cohen-Mansfield, PhD).

trast, behavior therapy interventions are based on a behavioral theoretical

model. Finally, environmental (Fig. 4) and combination therapies may relate
to any of the above theoretical models. For example, an environmental intervention may aim to decrease stimulation, in accordance with the environmental vulnerability/lower stress threshold model, or it may increase
stimulation based on an unmet need of boredom/need of stimulation.

Figure 3. Unmet needs of pain or discomfort: Examples of nonpharmacologic

and pharmacologic interventions. (Copyright 2013, Jiska Cohen-Mansfield, PhD).

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Fig. 4. Examples of environmental interventions for behavioral disorders in dementia. (Copyright 2013, Jiska CohenMansfield, PhD).

The above mentioned review of 83 intervention studies concluded that

the majority of interventions resulted in a positive impact, albeit not always significant, often due to design limitations [19]. While the field still
suffers from many of the same limitations, the following review will highlight recent findings concerning these interventions and discuss general
limitations, considerations, and trends.

Specific interventional procedure

Sensory interventions
Music
Music has received much attention as a therapeutic modality for behavioral disorders in dementia, and its impact in this context has been
examined in several recent reviews [2023]. These reviews found that
most studies demonstrated the efficacy or potential efficacy of music
therapy. Music therapy resulted in short-term reduction in behavioral
disorders and improvement in mood, but long-term impact was not
clear. Longer duration (over three months) of the music therapy intervention was associated with a greater effect on anxiety [20]. All of the
reviews noted the active or social features of music interventions. Two
reviews reported the element of singing as a positive contributor to behavioral change [20, 21] suggesting the importance of active participation, and another [22] stressed the importance of the ability of the music
therapist to interact directly with the person receiving the intervention.

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The focus on active participation and on human contact within music therapy raises the question concerning the net effect of music per se, ie, is listening to
music without any additional activity or input of value by itself? A study of the
use of such passive music in comparison to no stimuli has shown its effect in
reducing behavioral disorders [24] and increasing pleasure [25].

Aromatherapy
There are relatively few studies of aromatherapy interventions. A review of
11 randomized controlled trials [26] concluded that aromatherapy is potentially useful for treating behavioral disorders. A meta-analysis of two
studies [27, 28] in this review found a significant effect for aromatherapy
treatment. Interestingly, a replication of one of these studies, which included an improved experimental design (ie, blinding of treatment arms)
and a different assessment, did not find Melissa aromatherapy to be superior to placebo [29]. Overall, despite some positive results, current evidence
is inconclusive due to the small number of studies and methodological
limitations [26, 30].

Massage
A review of massage interventions for behavioral disorders in persons with
dementia [31] found only one study with adequate methodology [32] out of
13 studies that met review criteria. This study demonstrated a significant
reduction in behavioral disorders following massage in a sample of 52 persons with dementia. There was no comparison group. Several individual
studies support the impact of massage on behavioral disorders. Foot massage
has been associated with a significant decrease in behavioral disorders in 22
persons with dementia [33]. Massage was also associated with a significant
decrease in aggressiveness, but not in other behavioral disorders, in a group
of 20 persons with dementia. No significant changes in behavioral disorders
were found in the control group (n=20) [34]. In a study of 65 nursing home
residents with dementia, therapeutic touch significantly decreased restlessness, but not other behavioral disorders, in comparison to a control group
receiving routine care, and there was no significant reduction of behavioral
disorders in comparison with a placebo mimic treatment [35]. Taken together, massage intervention studies all suffer from methodological shortcomings or inconclusive results, often referring to a single behavioral
symptom. Nonetheless, they support the promise of massage and touch in
decreasing behavioral disorders in persons with dementia.

Multisensory interventions
Conflicting results have been found in studies of Snoezelen among persons
with dementia, with some studies reporting some effect on behavior but
others finding no effect [30].

Structured activities
The positive impact of activities, such as arranging flowers or arts and crafts,
has been demonstrated by several studies. In a comparison of different

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approaches to selecting activities for participants (eg, based on functional

level, personality style of interest, or both) it was found that all of the activities significantly decreased behavioral disorders, with no significant differences between those approaches [36]. In a study examining the efficacy of
various activities including tasks (eg, flower arrangement, coloring with
markers), reading stimuli (eg, being presented with a large-print magazine),
individualized activities matched to the individuals past preferences or
identity, work like activities (eg, stamping envelopes, folding towels), and
manipulative stimuli (eg, a tetherball, building blocks), all types of stimuli
and activities had a significant positive impact on behavioral disorders [37].
The greatest impact was found for task, reading, and self-identity stimuli (ie,
matched to prior relationships, occupation, hobby, or other attribute that
was important to the person), which significantly affected both physical and
verbal agitation. In contrast, work activities and manipulative stimuli had a
significant impact only on physical agitation [37].
A review of physical activity programs for persons with dementia [38]
concluded that these programs are beneficial for behavioral disorders.
Walking, however, did not appear to affect night-time restlessness [39]. An
exact specification of benefits by type of exercise, population, and behavioral
symptoms is needed. Dancing is a physical activity that also includes sensory
stimulation (music) and a social component. While most of the research is
descriptive and exploratory, a review of ten studies, seven of which were
qualitative, found that dance interventions decreased behavioral disorders
[40]. Indoor gardening is another type of physical activity that was reported
to significantly reduce behavioral disorders in a pilot pre-post study [41].
Montessori activities are based on principles developed by Maria Montessori for teaching children. These principles include matching task demand to
students abilities by breaking tasks into small components, using repetition,
and starting with easier items and then increasing demands as competence is
acquired. Typically, Montessori activities include a range of procedures that
may include sensory stimulation, such as rhythmic music, task type activities
based on utilizing procedural memory, such as pouring (eg, through a funnel) or squeezing (eg, clay), and social interaction. Two crossover studies
found that Montessori activities significantly decreased behavioral disorders
[42, 43], though in one of the studies [42] the comparison condition of
non-personalized activity was also effective, and both personalized and nonpersonalized activities included interaction , thereby potentially qualifying as
social contact interventions.

Social contact real or simulated

Given the definite impact of social contact on behavioral disorders and its
relative superiority to many other stimuli and activities [37], it is not surprising that it is an integral part of many nonpharmacologic interventions.
What is unexpected is the relative dearth of studies that address social contact
as the main intervention.
An analysis of the dimensions of social contact and their relative importance can be useful for devising interventions with a social contact component or focus. In a study that focused on engagement of nursing home
residents with dementia with activities and stimuli rather than on the treat-

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ment of behavior disorders, Cohen-Mansfield et al [44] analyzed the following dimensions: human vs nonhuman (ie, animal), realistic vs not realistic (eg, a doll that looks like a baby vs one that looks like a doll), animated
(eg, a robot with movement) vs not animated, and alive (eg, real baby or real
dog) vs not alive (eg, video, doll, or robot). While any social stimuli were
preferable to nonsocial stimuli in promoting engagement, attention, and a
positive attitude, there were advantages to human, animated, realistic, and
live stimuli. Nevertheless, there could be instances where engagement might
be longer for a not alive stimulus like a robotic dog rather than a live dog.
The following discussion of social interventions is divided to those that
provide human contact, animal-assisted social contact, and simulated social
contact.

Human contact
One-on-one human contact with a PWD by a trained individual has been
repeatedly found to be a highly potent intervention for behavioral disorders
[37, 45]. Humor therapy can serve as a source of social interaction, and it
was shown to significantly decrease agitation in a cluster randomized trial
[46] that utilized both trained staff and professional performers to deliver a
humor therapy intervention.

Animal-assisted interventions
A review of 18 studies of animal assisted interventions with persons with
dementia [47] shows that these interventions may have the potential to reduce behavioral disorders. Ten studies in this review examined the impact of
animal assisted therapy on behavioral disorders in dementia, of which three
reported statistically significant decreases in behavioral disorders [48, 49] or
aggressiveness [50]. The remaining studies either did not report a statistical
analysis or else reported nonsignificant results. While this review [47] suggested that robotic pets may be as effective as real live pets in terms of animal
assisted therapy, the evidence for this is still lacking [47, 51].

Simulated social contact

These interventions include a range of techniques to simulate human and
animal contact. Human contact can be simulated by calling to mind memories of past family relationships, such as through the use of family pictures.
Simulated presence therapy includes video or audiotaped conversations by
family members. Commercial respite videos, in which someone talks to or
sings with the older person, are also available. A baby doll may elicit caring
behaviors. Simulated contact with animals includes robotic animals (usually
cats or dogs), stuffed animals, and videos of animals [24].
The impact of video family simulated presence therapy has been demonstrated in a study utilizing a single subject ABA design [52]. Specifically, resistance to basic care was decreased during the presentation of the family
video; when the video was not presented, the effect was reversed. A review of
both audio and video simulated presence therapy [53] concluded, based on
four studies, that it has a significant positive effect on behavioral disorders,

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though with limited support. For simulated presence therapy to be useful,

several conditions need to be met: a positive relationship between the older
person and the family member preparing the tape, a family member willing
to prepare such a tape, cognitive impairment to a degree that will allow the
person to continue to enjoy the tape over repeated viewings, and hearing and
vision abilities sufficiently intact to utilize audio or videotape. Both anecdotal and research support has been documented regarding the beneficial
effect of using dolls with people with dementia, including the effect on behavioral disorders [54]. Dolls have been offered as an activity alternative in
this population or used in doll-therapy sessions. Dolls can offer comfort,
security, companionship, and a role to persons with moderate to advanced
dementia. Ethical concerns in using dolls involve scenarios in which the
PWD thinks the doll is a baby or becomes over-involved with the doll, along
with the need to protect the dignity of the PWD.

Medical/nursing care interventions

Behavioral disorders in general, and verbal agitation in particular, have been
shown to be associated with pain [3], and a large controlled study showed
that use of analgesics significantly decreased behavioral disorders in persons
with dementia [55]. Yet, the ability of both professional and family caregivers to detect pain in advanced dementia is questionable, and pain is
therefore underdetected and undertreated [56]. Different assessments for
pain have been compared for their efficacy to detect pain that responds to
analgesics. Informant ratings completed by primary direct-care caregiver were
the most useful in detecting pain in this population [57]. When analyzing the
type of behavior most likely to respond to pain medication, verbal agitation,
which has been shown to be most highly related to pain [3], also emerged as
having the largest response [58]. Despite the success of utilization of general
analgesics protocols, it is important to also investigate specific sources of
pain. Dental pain, for example, is pervasive in this population and can be
manifested in behavioral disorders [59].
In addition to pain, discomfort represents unmet needs that contribute to
behavioral disorders. Providing a sweater to someone who is feeling cold and
providing food, drink, and timely help in going to the bathroom are all examples of care activities that have been used to decrease behavioral disorders
[60]. A more comprehensive list of sources of discomfort is available
elsewhere [60]. The use of physical restraints, especially, results in discomfort that has been associated with increased behavioral disorders [61].
Conversely, the removal of such restraints has been associated with a decrease in behavioral disorders [62]. Removal of restraints requires a systemic
approach; an educational program is likely to be insufficient [63].
Discomfort is often experienced during the bathing process of persons
with dementia due to multiple sources, including poor understanding of
the PWD, lack of knowledge of staff members on how to provide a pleasant
bathing experience, a physical environment that does not meet the needs of
the PWD or the caregivers, and regulations that do not offer the flexibility
needed to provide tailored, person-centered bathing [64]. In a randomized
controlled trial [65], it was found that behavioral disorders and discomfort
significantly decreased when PWDs were provided with either person-cen-

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tered showering or a towel bath with no-rinse soap in comparison with usual
care.
Other medical/nursing interventions involve aids for vision and hearing
loss. While hearing loss is prevalent in dementia, the use of hearing aids is
relatively scarce [66]. A review of the limited reports on the impact of hearing
aids in dementia concluded that they do benefit the behavior of PWDs
(available in French; [67]).

Environmental interventions
A previous review on nonpharmacologic interventions [19] included
studies showing some support for the impact of enhanced environments,
such as those simulating natural conditions (eg, pictures of outdoors,
bird sounds) or a home environment in decreasing behavioral disorders.
Access to an outdoor garden, access to refreshments, and a quiet unit
have all been reported to decrease behavioral disorders [19]. Much of the
more recent literature on the impact of environmental change on PWDs
has not focused directly on behavioral disorders, but rather on constructs
that may either trigger behavioral symptoms or be incompatible with
them. For example, specific environmental features, such as small number of residents per unit, no change in direction within the unit layout,
and provision of only one living or dining room were related to better
way finding by residents [68]. Better way finding is likely to result in
more autonomy and less frustration and thereby the manifestation of
fewer behavioral symptoms. Similarly, design features, such as small unit
size, that are related to improved quality of life have been identified
[69]. Improved quality of life is generally incongruent with behavioral
disorders [70]. The same review [69] reported that decreasing the institutional characteristics of residential facilities was associated with fewer
behavioral disorders and that a wall mural over an exit door decreased
exit attempts. Finally, bright light therapy, used in a study of 66 older
PWDs in two residential care settings, showed no benefit and a potential
exacerbating effect and remains a controversial modality for behavioral
disorders in dementia [71].

Behavior therapy
Previous studies have showed the efficacy of differential reinforcement and
stimulus control in treating behavior disorders yet the evidence is limited
because most used a single subject design or very small samples [19]. In
recent years there seems to be a dearth of studies using behavior therapy
compared with those investigating other approaches. Yet, the few studies
conducted have generally supported behavior therapy for treating behavior
disorders. For example, a single subject design demonstrated the impact of
both stimulus control and differential reinforcement on wandering behavior
[72], and a pilot study using a pre-post design reported significant improvement in behavioral disorders [73].

Culture change, system change, and staff training

Staff training is undertaken in order to affect behavior change in staff
that will then result in reduction in behavioral disorders in PWDs under

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their care. These complex interventions can target various groups or

organizational levels and may include person-centered care or specific
interventions.
The results of staff training interventions thus far have been mixed. In a
Cochrane review, four studies that successfully decreased antipsychotic
medication use in care home residents were identified. The outcome was
achieved using a variety of educational methods, including education and
training of physicians, pharmacists, and nursing staff, as well as consultations
with the home administrator, information meeting for family members,
multidisciplinary team meetings, and additional education for all staff who
come in contact with residents [74]. An exploratory trial with no control
group found that a staff training intervention [75] significantly reduced behavioral disorders in 32 assisted-living residents with dementia. In a randomized controlled trial [76], an education and supervision intervention
significantly reduced behavioral disorders at 6- and 12-month follow-up in
145 nursing home residents with dementia when compared with controls.
The program included lectures, written materials, provision of resources to
implement the new skills, feedback and peer support. Another controlled
study that significantly reduced behavioral disorders [77] utilized a combination of lectures, instruction cards, and individual and iterative sessions
providing instruction and feedback as to how to handle behavioral problems. The trainers were also available to staff members at designated times to
provide training and advice.
Other staff interventions did not appear to be successful in reducing behavioral disorders. A review of case conferences for handling behavioral
disorders [78] reported that four of the seven identified studies showed a
reduction in behavioral disorders and concluded that there is little evidence
for the utility of case conferences. Other interventions included the use of a
multi-component education toolkit utilizing an assessment to trigger care
planning of persons with behavioral disorders [79], as well as an attempt to
improve staff interaction with residents with severe dementia by training
them to observe and identify awareness in residents [80]. Adherence is often
a problem in staff training programs [81].
Culture change implies a greater institutional change than staff training.
In a longitudinal study examining culture change that focused on providing person-centered care, a significant benefit on behavioral disorders was
reported; however, the benefit was accounted for by significant increases in
behavior disorders in the control communities while the intervention communities maintained pre-intervention levels [82]. This equivocal result
suggests that future research of culture change interventions may need to
examine the impact of specific aspects of such programs or of specific combinations of elements in order to ascertain the necessary ingredients to affect
change.
One example of successful system change is provided in the experience of
the Kansas Bridge Program, a dementia crisis intervention program utilizing
support to family caregivers of persons with behavioral disorders by a trained
social worker and improving education and coordination among professionals working with PWDs. The program resulted in multiple significant
benefits for PWDs and their caregivers, including a reduction in PWDs' behavioral disorders [83].

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Combination therapies / complex algorithms

The rationale behind the use of algorithms that utilize a combination of
interventions is that both the type and specifics of an intervention need to be
matched to the person, setting, situation, and resources. The particulars of the
individualization process differ across studies. The Treatment Routes for
Exploring Agitation TREA approach first assesses the unmet needs of the
individual. Each type of unmet need can be addressed by a range of interventions, so that the specific intervention is selected to meet the persons
sensory (eg, vision and hearing) and mobility abilities, as well as past and
present preferences. Understanding past and present preferences can be facilitated by the use of assessments such as the Self-Identity in Dementia
questionnaire [84] or the SHAPE Self Maintenance Habits and Preferences
in Elderly [85]. The efficacy of this TREA algorithm approach has been reported in two studies [60, 86]. A similar approach was taken in a program
titled Behavior-based ergonomics therapy - BBET, which provided individualized relaxing and stimulating activities and stimuli on a preventive
basis, ie, on an ongoing basis rather than after a disruptive behavior. This
decreased behavioral disorders and use of psychotropic medication [87].
Similarly, an individualized intervention addressing needs for comfort, social
interaction, and sensory stimulation significantly decreased verbal agitation
[88]. Another intervention with caregivers of home-residing PWDs that successfully reduced behavior disorders utilized home and telephone contacts
between an occupational therapist and the caregiver that addressed communication, environmental problems, and medical issues while also brainstorming concerning problems reported by the caregiver [89]. Finally, a
review of 18 functional analysis-based interventions drawing on various
theoretical orientations to individualize interventions within a wide range of
settings, including family care and care homes, found that the frequency of
behavioral disorders decreased after the interventions [90].

General issues in research and implementation

of nonpharmacologic interventions
The level of evidence, and does it make a difference?
There is an abundance of reviews of the impact of nonpharmacologic interventions on behavior problems, and several reviews of reviews [91]. Many of the
reviews exclude much evidence by insisting on randomized controlled trials
as an inclusion criterion [Cohen-Mansfield et al., Expanded review criteria:
the case of nonpharmacological interventions in dementia, unpublished manuscript]. One review of reviews concluded that three types of interventions are
effective: music, massage, and physical activity [91], while another found behavior therapy, cognitive stimulation, and physical activities to be effective [92].
Such discrepancies raise the question of whether it is helpful to focus on proof
of efficacy rather than proof of promise. I would like to argue that an efficacybased approach to clarifying the level of evidence is not useful. This conclusion
is based on practical, methodological, and theoretical considerations.
From a theoretical point of view, given that the bulk of the evidence
points to unmet needs as an appropriate framework for understanding
most behavioral disorders, it can be expected that different PWDs have dif-

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ferent needs and even the needs of a single PWD will vary by time. Moreover,
the proper response to a need is unique and is a function of the persons
abilities, habits, and preferences. Therefore, any study that uses the same
specific intervention for all participants is likely to have a moderate impact at
best. An effort, instead, is needed to provide a proof of concept or feasibility
for a wide range of potential solutions. Efficacy should be examined for research of algorithms utilizing these solutions or for research of change of
culture of practice style, which also likely would utilize these solutions.
From a methodological point of view, the determination of whether a trial
shows a significant effect often seems to depend as much on the procedures
used as on the results. The label of a nonpharmacologic intervention does
not itself indicate the active ingredient(s) in that intervention. Clarifying the result of an intervention is therefore confounded by several factors. The quality
and frequency of interactions with the person administering the intervention
may have a major effect on its outcome. The impact of the intervention on
the caregiver is also important, as the intervention may require extra effort from
the caregiver, it may have a direct impact on the caregiver (eg, music) or, alternately, provide tools to care for the PWD or result in the PWD becoming more
amenable to care. Prior attitudes toward the intervention modality (music, pet,
manipulative object, game) can also affect the response to the intervention. The
setting of the intervention and dosage (eg, duration, timing, and frequency) can
all affect the response. It is extrinsic factors such as these that can lead different
studies and different reviews to reach different conclusions for ostensibly the
same intervention. Further clouding the issue are inadequate reviews that repeat
the results of other inadequate reviews to provide either a thoroughly vague and
ambiguous picture or to recite the need for additional research and reiterate the
known limitations of studies in this field. This approach is neither informative
nor useful for practice or research in this area.
A practical point of view would indicate that, as can be seen in Figs. 1, 2, and
3, nonpharmacologic approaches encompass a multitude of techniques and
procedures and, therefore, it is unlikely that sufficient resources will be available
to perform properly powered randomized controlled studies on all of these interventions. Moreover, each intervention encompasses many particular exemplars, such that a doll may be small or baby size, soft or plastic, baby-like or
not, of the same race as the PWD or a different one, etc, or a physical exercise
may differ by type of activity, by person providing it and the amount and type
of communication and support provided, by the number of PWDs included in
the activity, and other attributes. It is definitely impossible to study each of these variants in a large study. Studies comparing attributes of interventions to clarify the crucial dimensions, which impact efficacy may ultimately be more
useful. However, those studies are often not considered for inclusion in reviews
because they do not fit the current devotion to the RCT design [Cohen-Mansfield et al., unpublished manuscript].

Contraindications, complications, adverse events, and negative results

Because of the nature of nonpharmacologic interventions, they have very few
adverse events or contraindications, and reports of these are rare. One example of an adverse event involved a family video that resulted in an exacerbation of problem behaviors. Upon further inquiry, the researchers found

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out that the relationship between the PWD and the family member who had
produced the video had been strained for years [93]. This incident exemplifies the importance of fitting the intervention to the personal characteristics of the PWD, not just in terms of cognitive and physical abilities and
sensory deficits, but also in terms of the particular meaning of the intervention to the person. Accordingly, animal-assisted therapy is more likely to
help persons who liked pets. Because not all background information can be
gained prior to an intervention, some studies have used an initial trial period
to assess and refine the particulars of the intervention prior to providing it on
a more prolonged basis [25]. Such a trial period is a good opportunity to
document both refusals and nonresponse, which have been understudied in
past research.
Reports of negative results, ie, of interventions that did not produce the
anticipated effect on problem behaviors, can still be insightful, particularly
given the multiple limitations of studies in this area. Indeed, despite publication bias, there are nevertheless many reports of negative results [94, 95].
Such studies demonstrate the difficulty of affecting change in a population of
persons with advanced dementia, who are often cared for in conditions that
may be difficult for them and/or their caregivers. This situation needs to be
kept in mind in reviewing the results of the imperfect research that constitutes most of the knowledge currently available, and potentially much of
what will be available in the foreseeable future.

Cost/cost-effectiveness
The dearth of information concerning cost-effectiveness of
nonpharmacologic interventions in dementia is due to the complexity of the
calculations and to the underdeveloped nature of the interventions themselves. Calculating the cost effectiveness of the interventions would need to
take into account any system changes (eg, training and mentoring caregivers,
providing necessary materials, etc) required to make nonpharmacologic interventions a part of daily life in the care of the PWD. Necessary funds could
potentially be achieved through savings in costs associated with pharmacologic care, currently the common practice in the clinical management of
behavioral disorders, such as medicine aids, physician calls, handling of
adverse events, etc. One study that did examine the cost-effectiveness [96] of
home visits by occupational therapists to develop customized activities and
train families in their use concluded that the program was cost-effective.

Comparing treatments to each other

Given the large range of nonpharmacologic interventions, the practitioner
would benefit from information about their relative efficacy. Yet, that
knowledge is currently limited.
A few studies have reported an equivalent efficacy of different interventions in reducing behavior disorders. These included comparisons of music
therapy and recreational activities [97], Snoezelen and reminiscence therapy
[98], and Person Centered Showering and Towel Bath, which were both superior to usual care [65].
Other studies have reported both equivalent and differential efficacy in reducing behavior disorders when comparing different interventions. For ex-

Nonpharmacologic Treatment of Behavioral Disorders in Dementia

Cohen-Mansfield

779

ample, one-on-one social contact, videotapes of family members, and music

were all more effective than usual care in reducing verbal agitation, but oneon-one social contact was the most effective [45]. Another study reported
that, while both simulated family presence and preferred music reduced
physical agitation, only simulated family presence significantly reduced verbal agitation [99]. Comparison of eight stimulus categories revealed a hierarchy among stimuli with regard to their ability to decrease agitation. Human
social interaction was the most effective intervention, while manipulative
stimuli were the least effective. The other categories of stimuli, such as those
based on the persons self-identity had an intermediate level of impact [37].
The ultimate goal of such comparisons is to clarify which intervention is best
for whom.

Long-term vs short-term impact

One of the common criticisms of nonpharmacologic interventions is that
their effects are of short duration, only being seen while the intervention is
actually taking place but not at post-trial follow-up [45, 49]. It is to be
expected that interventions addressing unmet needs would satisfy those
needs while the intervention is ongoing (eg, providing an activity to a person
who is bored and unable to engage herself or elimination of pain and discomfort), but the need still remains after the intervention is stopped. For
providing nonpharmacologic interventions that meet continuing needs, environmental, technological, system, and care changes would need to be
effected, often providing continuous intervention.

Requirements for translation/barriers

A successful implementation of nonpharmacologic interventions requires
caregivers to effectively communicate with PWDs at the highest level possible; to observe the PWDs behaviors and their antecedents and consequences;
to know the past habits, preferences, and identities of the PWD; to empathize
with the predicament of the PWD, who often confronts an environment that
is inexplicable to him/her with limited sensory, communicative, and cognitive tools; and to effectively problem solve how to best utilize the wide
toolkit of interventions to address the needs of the PWD. Insight into what is
needed to achieve this level of care can be obtained from the description of a
culture change initiative within a nursing-home setting. Some steps taken to
provide person-centered care include the creation of a staff coordinator and
mentor position, staff and family education, organizational changes, focusing on tailored activities, and environmental changes [82].
Several barriers to the implementation of nonpharmacologic interventions have been identified. These include staff-related barriers, such as denial of unmet need, refusal to provide for a need, or lack of access to a
physician; family-related barriers, such as unavailability or lack of cooperation in providing information about the persons past or memorabilia to
help devise appropriate interventions; and environmental barriers, such as
uncomfortable surroundings [100]. Strategies to address barriers to
nonpharmacologic interventions have also been proposed. For example,
within the context of bathing PWDs at home [101], it was concluded that to
improve the process of care there is a need to conduct in vivo observations to

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DEMENTIA (E MCDADE, SECTION EDITOR)

examine behavioral triggers and caregiver skills; to clearly identify the identity of the caregiver responsible for care; to develop a trusting relationship
between the mentor and the caregiver; and to provide ongoing coaching,
modeling and support to the caregivers.
Another practical barrier to implementation of nonpharmacologic intervention is the lack of clear professional expertise in this topic. While there
are nurses, social workers, psychologists, occupational therapists, and others
who do have such expertise through their clinical or research work, this expertise is unique to those individuals and not yet generally provided as part
of a specific training program or certification. This is a direction for future
development.
In summation, this review indicates that the study and practice of a wide
range of nonpharmacologic interventions for behavioral disorders in dementia is increasing. Some interventions, particularly those that are based on
the unmet needs model and utilize individually-tailored interventions, show
more promise than others. However, the existing level of evidence is limited
due to various theoretical, methodological, and practical concerns that need
to be taken into consideration in order to promote the successful investigation of nonpharmacologic interventions for behavioral disorders and the
delivery of efficacious person-centered care.

Acknowledgment
This work was supported in part by the Minerva-Stiftung Foundation grant no. 31583295000.

Compliance with Ethics Guidelines

Conflict of Interest
Jiska Cohen-Mansfield declares that she has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with animal subjects performed by the author. With regard to the
authors research cited in this paper, all procedures were followed in accordance with the ethical standards
of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as
revised in 2000 and 2008.

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