Running head: NONPHARMACOLOGICAL INTERVENTION DEMENTIA 1

Nonpharmacological Intervention on Patients with Dementia

Paige Guers

University of South Florida

NONPHARMACOLOGICAL INTERVENTION DEMENTIA 2

Abstract

Clinical Problem: Patients with dementia suffer from neuropsychiatric symptoms including

aggressive and agitated behavior, depression, anxiety, and restlessness. When these symptoms

are exhibited, care can be overwhelming for the caregiver. The pharmacological treatment has

modest benefits but the side effects can be severe.

Objective: To determine if individualized activities can influence behavioral and affective

symptoms of patients with dementia. CINAHL, PubMed, and National Guideline Clearinghouse

were accessed to obtain the trials and the guidelines concerning the treatment of dementia

patients. Key search terms included dementia, behavior, agitation, treatment, and

nonpharmacological.

Results: The Hartford Institute for Geriatric Nursing recommends the use of cognitive-

enhancement techniques; adequate rest, sleep, nutrition, and pain control; addressing behavioral

issues; and ensuring a safe and therapeutic environment (Fletcher, 2012). The literature

demonstrated lower rates of neuropsychiatric symptoms and improvement of patient behavior

when providing nonpharmacological intervention individualized for each patient.

Conclusion: Interventions reduced the rates of behavioral problems and additionally decreased

the use of psychotropic in patients with dementia. However, this may not be a benefit to patients

with dementia unless individualized stimuli and social interaction are available.
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Nonpharmacological Intervention on Patients with Dementia

Alzheimers Disease is the most common form of dementia, characterized by memory

impairment, and decreased ability of reasoning, planning, language, and perception (Osborn,

Wraa, Watson, & Holleran, 2014). The symptoms gradually lead to behavior and personality

changes, a decline of cognitive abilities, and difficulty recognizing family and friends (Osborn,

Wraa, Watson, & Holleran, 2014). Common symptoms are confusion, memory loss, difficulty

accomplishing simple tasks, misplacing things, progressive memory loss, mood swings and

personality changes (Osborn, 2014).

Currently, the main treatment for dementia is a pharmacological approach to preserve

cognitive and functional abilities and slow the progression of the disease (Osborn, Wraa,

Watson, & Holleran, 2014). Psychotropic drugs are used to treat restlessness, agitation, anger,

anxiety, or wandering (Osborn et. al, 2014). While there are modest benefits from a

pharmacological intervention, there are negative side effects including anticholinergic reactions,

parkinsonian events, tardive dyskinesia, sedation, cognitive slowing, and death (Osborn et al,

2014). There is growing evidence to support a person-centered care and nonpharmacological

interventions for the management of neuropsychiatric symptoms (Ballard et al., 2016). The

PICOT question supporting the topic is (P) In patients with Alzheimers (I) How do

individualized activities (C) Compared to usual care (O) Influence behavioral and affective

symptoms (T) Over one year? The expected outcome is a reduction of neuropsychiatric

symptoms.
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Literature Search

CINAHL, PubMed, and the National Guideline Clearinghouse were accessed to obtain

the trials and the guidelines concerning the treatment of dementia patients. Key search terms

included dementia, behavior, agitation, treatment, and nonpharmacological. The search was

limited to peer-reviewed articles and randomized controlled trials.

Literature Review

Using a cluster-randomized 2x2x2 factorial controlled trial with two replications, Ballard

et al. (2016) assessed the impact of antipsychotic review, social interaction, and exercise along

with person-centered care, on agitation, antipsychotic use, and depression in nursing home

residents with dementia compared to those not receiving the antipsychotic review. There were

277 residents in 16 nursing homes randomly assigned to the treatment and control groups. Eight

homes were assigned to an antipsychotic review, a social interaction intervention, and an

exercise intervention for nine months. Assessments were done at baseline and after 9 months of

intervention. After the antipsychotic review, there was a significant reduction in the use of

antipsychotics use compared to the non-review group (p=0.006). Patients who received

antipsychotic review and social interaction had a significant decrease in neuropsychiatric

symptoms compared to baseline (p=0.02). Patients assigned the exercise treatment had a

significant improvement in neuropsychiatric symptoms (p<0.05). The strengths of the trial were

randomization of nursing homes, an adequate population size, assessments before randomization

occurred, reasons why subjects did not complete the study, a follow-up after 9 months, an

appropriate control group receiving care as usual, reliable instruments used to measure outcomes,

and participants of similar demographics and who met the inclusion criteria at each participating

nursing home.
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Using a randomized controlled trial of participants in 7 nursing homes, Cohen-Mansfield

et al. (2010) assessed the impact of 8 different types of stimuli including music, social stimuli,

simulated social stimuli, and individualized stimuli based on the patients self-identity on

agitated behaviors in nursing home residents with a diagnosis of dementia. There was a total of

111 residents of nursing homes with a diagnosis of dementia who exhibited agitation. Each

resident was presented with 25 predetermined stimuli over a period of 3 weeks. All participants

received the same standardized treatments in randomized order. Baseline observations were

taken daily for each participant, before engagement of the stimuli. All stimuli categories were

associated with significant decrease in physical agitation compared to baseline (p<0.001), and all

categories except for manipulative stimuli were associated with less total agitation (p<0.001).

Live social stimuli, which included a real baby, a real dog, and one-on-one socializing, showed

the best results (p<0.01). The strengths of this trial were randomization of stimuli, all patients

were of a similar demographic, clear criteria for exclusion was defined and reasonable, baseline

assessments were taken by one provider and outcomes were determined by another provider who

didnt meet the patient, and the instruments used to measure outcomes were reliable. A

weakness of the study is the short length of the trials. Trials lasted only 3 minutes, which

provided only an immediate reaction to the stimuli. Additionally, all participants in this trial

received treatment. It is unclear if the subjects were analyzed in the group to which they were

randomly assigned.

Using a cluster randomized controlled trial, Pieper et al. (2016) assessed whether a

stepwise multicomponent intervention was effective in reducing challenging behavior and

depression in nursing home residents with dementia. The sample (n=288) included nursing

home residents and 21 total nursing home units. The nursing homes were randomly assigned to
NONPHARMACOLOGICAL INTERVENTION DEMENTIA 6

treatment or control groups. Participants received the STA OP! intervention (n=148) or received

care as usual (n=140). Residents who received the intervention had significantly lower rates of

agitation (p=0.02), psychotropic medication use and neuropsychiatric symptoms (p=0.005), and

symptoms of depression (p<0.001) compared to the control group. Strengths of this study

include cluster randomization, assignments were concealed from those who were first enrolling

subjects into the study, single-blinding of the staff, randomization of participants using a

computer software, reasons for participants who did not complete the study, follow up

assessments after 3 months and 6 months, a control group that received care as usual, reliable

instruments used to measure outcomes, and participants of a similar demographic.

The guidelines provided by the Hartford Institute of Geriatric Nursing (2012) for the best

management of dementia are based on evidence-based geriatric nursing protocols. The Hartford

Institute recommends providing adequate cognitive-enhancement techniques and social

engagement in patients with dementia. It recommends defining the target symptoms such as

aggression, agitation, or wandering, encouraging an exercise routine to expend energy and to

promote fatigue at bedtime, and ensuring an environment that is modestly stimulating and

therapeutic.

Synthesis

Ballard et al. (2016) demonstrated a significant interaction between antipsychotic review

and social interaction. Patients who received antipsychotic review and social interaction had a

significant decrease in neuropsychiatric symptoms compared to baseline (p=0.02). Patients

assigned the exercise treatment had a significant improvement in neuropsychiatric symptoms

(p<0.05). Cohen-Mansfield et al. (2010) determined a reduction in agitation with the use of

personal stimuli. All stimuli categories were associated with significant decrease in physical
NONPHARMACOLOGICAL INTERVENTION DEMENTIA 7

agitation compared to baseline (p<0.001). All categories except for manipulative stimuli were

associated with less total agitation (p<0.001). Pieper et al. (2016) demonstrate a reduction in

challenging behaviors using the STA OP! method (p<0.05). The guidelines recommend

providing social engagement and a modestly stimulating environment. Under-stimulation may

result in sensory deprivation and withdrawal (Fletcher, 2012). While the interventions in each

study differed, the results of each showed a similar improvement in neuropsychiatric behaviors

when adding individualized activities to usual care. Since every patient has different interests, it

is important to work with each patient individually and determine which activity is the most

effective.

Clinical Recommendations

Based on the synthesis of the literature, the clinical recommendations for managing

behavioral disturbances in patients with dementia are personalized activities in addition to

normal care. These non-pharmacological techniques should be used as a first line of defense

before the use of psychotropic medications are initiated. Examples of non-pharmacological

treatments include exercise, social engagement, music therapy, and other individualized

activities catered to the patients needs (Ballard et al., 2016; Pieper, 2016; Cohen-Mansfield,

2010).
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References

Ballard, C., Orrell, M., YongZhong, S., Moniz-Cook, E., Stafford, J., Whittaker, R.,

Fossey, J. (2016). Impact of antipsychotic review and nonpharmacological intervention

on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia

living in nursing homes: a factorial cluster-randomized controlled trial by the well-being

and health for people with dementia (WHELD) program. American Journal of

Psychiatry, 173(3), 252-62. doi:10.1176/appi.ajp.2015.15010130

Cohen-Mansfield, J., Marx, M. S., Dakheel-Ali, M., Reigier, N. G., Thein, K., Freedman, L.

(2010). Can agitated behavior of nursing home residents with dementia be prevented

with the use of standardized stimuli? Journal of the American Geriatrics Society, 58(8),

1459-64. doi:10.1111/i.1532-5415.2010.02951.x

Osborn, K. S., Wraa, C. E., Watson, A. B., and Holleran, R. (2014). Medical-surgical nursing

preparation for practice. Boston, MA: Pearson.

Pieper, M. J. C., Francke, A. L., Van der Steen, J. T., Schrerder, E. J. A., Twisk, J. W. R.,

Kovach, C. R., and Achterberg, W. P. (2016). Effects of a stepwise multidisciplinary

intervention for challenging behavior in advanced dementia: A cluster randomized

controlled trial. The American Geriatrics Society, 64(2), 261-69. doi:10.1111/jgs.13868

Fletcher, K. (2012). Evidence-based geriatric nursing protocols for best practice. New York,

NY: Springer Publishing Company, 4, 163-85. Retrieved from https://www.guidelines.

gov/summaries/summary/43921/recognition-and-management-of- dementia-in-

evidencebased-geriatric-nursing-protocols-for-best-practice?q=dementia