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Nonpharmacological Interventions Are the Most Effective for Treating Neuropsychiatric Symptoms of Dementia

      Graphical abstract

      Clinical Quandary: Multiple complaints have been raised by staff and various family members about a long-term care resident with vascular dementia who is increasingly verbally abusive toward staff, other residents, and visitors. The resident has also begun hitting the staff when they attempt to provide daily personal care. There are multiple avenues available to address behaviors in the nursing home setting. Yet the medical director, administrator, and director of nursing must all balance an effective treatment plan with the desire to prevent staff burnout and ensure the safety of residents, visitors, and staff.
      Clinical Questions: Which evidence-based interventions are most effective for treating the neuropsychiatric symptoms of dementia in a long-term care facility? Are there recommended interventions to prevent staff burnout?
      Bottomline: Pooled evidence has shown that nonpharmacological interventions such as outdoor activities, massage and touch therapy, and modifications of activities of daily living (ADL) are the most effective interventions for treating aggression and agitation in persons with dementia. The emphasis should be placed on nonpharmacological interventions rather than medications to address the neuropsychiatric symptoms of dementia. This person’s behavior likely has meaning, which can be more reliably uncovered and addressed through the nonpharmacological interventions and assessments. Consideration also should be given to caregiver tools to lessen their burden and potential for burnout. One resource that deserves study to see whether it can be adapted for post-acute and long-term care settings is Powerful Tools for Caregivers.
      Summary: A large systemic review incorporating network meta-analysis (which compares three or more treatments within and across multiple randomized clinical trials) was published at the end of 2019 comparing multiple pharmacological and nonpharmacological interventions used to treat aggression and agitation in persons with dementia [Ann Intern Med, Oct. 15, 2019; doi:10.7326/M19-0993]. The main outcome measure was change in aggression, and secondary outcome was change in agitation. Specifically, the authors looked at physical aggression or agitation, verbal aggression or agitation, combined physical and verbal aggression, and combined aggression and agitation.This study is important because it combines and compares the existing evidence to reinforce the value of nonpharmacological care in the treatment of dementia symptoms.
      Overall, the nonpharmacological interventions were the most highly ranked interventions (see the table). For verbal agitation alone, no interventions were found to be efficacious. Most of the study’s participants were women in nursing homes over the age of 80, and most of the treatment comparisons were at high risk for bias because of missing data and slight differences in the scale used as the outcome measure. This study is important because it combines and compares the existing evidence to reinforce the value of nonpharmacological care in the treatment of dementia symptoms. Health systems and policy changes are needed to better support nursing homes in providing evidence-based care to these residents.
      TableEffective Interventions for Behavioral Issues in Persons With Dementia
      Physical Aggression (22 studies, 2,780 patients)Verbal Aggression (15 studies, 1,736 patients)Physical Agitation (26 studies, 2,597 patients)Verbal Agitation (21 studies 2,247 patients)Combined Agitation and Aggression (148 studies, 21,686 patients)
      More EffectiveLess EffectiveMore EffectiveLess EffectiveMore EffectiveLess EffectiveMore EffectiveLess Effective
      • Outdoor activitiesa
      • ADL modificationb
      • Massage and touch therapyc
      • Outdoor activities
      • Antipsychotics
      • Caregiver educationd
      • ADL modification
      • Massage and touch therapy
      • Usual caree
      • Caregiver education
      Massage and touch therapy
      • Usual care
      • Caregiver Education
      No effective interventions
      • Recreation therapyf
      • Multidisciplinary careg
      • Massage and touch therapy
      • Musich combined with massage and touch therapyi
      • Cognitive Stimulationi,g
      • Cannabinoidsk
      • Dextromethorphan-quinidinek
      • Usual care
      • Placebo
      a Going outside to do horticulture-based activities
      b Any activity that modifies at least one ADL
      c Massage, acupressure, therapeutic touch
      d Providing written or oral education to caregivers
      e Standard of care as per setting
      f Activities including playing games, reading, and cooking
      g Care plan developed by more than one health-care provider (e.g., nurse or physician)
      h Listening to music, playing musical instruments, dancing or movement to music
      i Based on subgroup analysis of nursing home or assisted living studies
      j Tasks to train specific cognitive domains (e.g. executive function, working memory)
      k Based on subgroup analysis of studies that used standard diagnostic criteria for dementia
      ADL, activities of daily living
      In addition, trial and error with nonpharmacological interventions to treat the neuropsychiatric symptoms of dementia can be exhausting for staff. Powerful Tools for Caregivers (PTC), a nonprofit organization (powerfultoolsforcaregivers.org), offers a series of six weekly, 2-hour classes designed for community caregivers. The classes address caregiver self-care, management of emotion, improved communication, self-confidence in coping with caregiving demands, and use of community resources [J Am Med Dir Assoc, Dec. 19, 2019; doi:10.1016/j.jamda.2019.11.011].
      The PTC program is delivered through collaborations with community-based organizations, such as continuing care retirement communities, senior centers, and places of worship, and it is free for participants. The study found that the behavioral symptoms of the care recipient (the person with dementia) did not change, but the community of informal caregivers manifested medium to large decreases in caregiver burden, decreases in caregiver depression, and increases in caregiver self-efficacy. This intervention has not been studied for institutional caregivers, and it warrants further investigation in this setting.
      Dr. Buhr is an associate professor at Duke University in the Division of Geriatrics, Department of Internal Medicine. Her interests include geriatric and long-term care education, quality improvement, and transitions of care.
      Dr. Little is an associate professor of Geriatric Medicine at Duke University. Her scholarly interests are interprofessional health education, deprescribing, and nonpharmacological management of dementia.