Neuropsychiatry of Dementia: Nonpharmacologic Interventions for Inappropriate Behaviors

In the past, it was not believed that persons with dementia retained high­er-level needs or functions. We have since learned, however, that although persons with dementia differ from cognitively intact persons in their ability to articulate and independently meet higher-level needs, these needs are present nonetheless (Cohen-Mansfield and Werner 1995). Evidence shows that a large proportion of dementia-related behavior problems stem from an incongruence between the needs of the person who suffers from demen­tia and the degree to which his or her environment fulfills these needs (Bar­ton, Findlay, and Blake 2005; Cohen-Mansfield and Werner 1995; Palmer et al. 1999). In fact, it is our experience as well as that of other researchers that many behavior problems constitute a response to physical pain or dis­comfort (Cohen-Mansfield et al. 1990; Douzjian, Wilson, and Shultz 1998), feelings of loneliness or isolation (Cohen-Mansfield and Werner 1997), boredom (Buettner and Kolanowski 2003; Ice 2002), or sensory deprivation (Cohen-Mansfield 2000b). Thus, many “problematic behaviors” may rep­resent a cry for help, a result of unmet needs, or an inadequate attempt to fulfill those needs. For example, Hancock, Woods, Challis and Orrell (2006) found that sensory or physical disability (including mobility problems and incontinence) needs, mental health needs, and social needs of persons with dementia in residential care were often unmet and were associated with psychological problems such as anxiety and depression. Due to such find­ings, it is critical that the evaluation and care of unmet needs become the guiding principles of good, domain-specific patient care.

Nonpharmacologic interventions aim to address what we have learned to be the most important etiologic basis of behavioral problems in demen­tia. Similar to the notion of “person-centered care” (Touhy 2004), this approach can be better described as “informed care,” a treatment approach that is based on knowledge of the needs of persons with dementia in gen­eral and the individual in particular. Care can be enhanced by an approach of rehabilitation and restorative care, yet the main focus is that of improv­ing overall well-being and addressing the needs of the older individual with dementia, even when those needs are not obvious or articulated. Admittedly, the implementation of this type of care is more complex than prescribing a psychoactive medication, and the identification of the needs to be fulfilled is more difficult than articulating the specific psychi­atric syndrome from which the patient may be suffering. However, these interventions avoid the potentially harmful side effects that result from pharmacologic treatments (Ballard et al. 2009; Folks 2003; Gill et al. 2009). Also, reducing inappropriate behaviors via sedation with psychoactive medication can potentially rob the person with dementia of the very lim­ited resources he or she has in either expressing or attending to his or her needs (Cohen-Mansfield 2000a; Fisher and Swingen 1997), thereby dimin­ishing the ability of caretakers to detect and address the true underlying need. Most important, nonpharmacologic interventions aim to improve the quality of life of the person with dementia.

In summary, the importance of utilizing a nonpharmacologic approach for inappropriate behaviors associated with dementia is threefold: (a) it aims to address the psychosocial/environmental underlying reasons for the behavior, which have been documented in prior research, thus increas­ing quality of life; (b) it avoids the limitations of pharmacologic interven­tions, namely adverse side effects, drug-drug interactions, and limited efficacy (Cohen-Mansfield et al. 1999); and (c) when medication is effica­cious, it may mask the actual need and reduce the already compromised communication by the older person, thereby limiting the caregiver’s abil­ity to properly care for that person.