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Paige Guers
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
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
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.
NONPHARMACOLOGICAL INTERVENTION DEMENTIA 3
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
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,
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.
NONPHARMACOLOGICAL INTERVENTION DEMENTIA 4
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
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
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
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
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.
NONPHARMACOLOGICAL INTERVENTION DEMENTIA 5
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
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
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
engagement in patients with dementia. It recommends defining the target symptoms such as
promote fatigue at bedtime, and ensuring an environment that is modestly stimulating and
therapeutic.
Synthesis
and social interaction. Patients who received antipsychotic review and social interaction had a
(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
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
normal care. These non-pharmacological techniques should be used as a first line of defense
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).
NONPHARMACOLOGICAL INTERVENTION DEMENTIA 8
References
Ballard, C., Orrell, M., YongZhong, S., Moniz-Cook, E., Stafford, J., Whittaker, R.,
and health for people with dementia (WHELD) program. American Journal of
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
Pieper, M. J. C., Francke, A. L., Van der Steen, J. T., Schrerder, E. J. A., Twisk, J. W. R.,
Fletcher, K. (2012). Evidence-based geriatric nursing protocols for best practice. New York,
gov/summaries/summary/43921/recognition-and-management-of- dementia-in-
evidencebased-geriatric-nursing-protocols-for-best-practice?q=dementia