A checklist of approaches for alleviating behavioral problems in dementia

Dementia—“major neurocognitive disorder” in DSM-5—manifests as progressive decline in cognitive function.In tandem with that decline, approximately 80% of nursing home patients with dementia exhibit behavioral disturbances,¹ including irritability, insomnia, wandering, and repetitive questioning.^1,2 These disturbances can erode their quality of life and can frustrate caregivers and providers.³

Causative pathology
Before designing a therapeutic intervention for cognitively impaired people with behavioral disturbances, a precise diagnosis of the causative pathology must be determined. This affords therapies that specifically address the patient’s problems. Other related and unrelated somatic or mental health concerns should be identified to specify the optimal approach.

Patients in whom dementia is suspected require that a thorough medical, psychiatric, substance use, and family history be taken to identify predisposing factors for their illness²; exhaustive review of the history might reveal drug interactions or polypharmacy that can cause or exacerbate symptoms, including behavioral manifestations. Physical examination, cognitive function testing, laboratory tests, and neuroimaging also help reveal the etiologic diagnosis of the dementia.^1,3

Identifying the diagnosis directs the treatment; for example, a behaviorally discontrolled person with a cognitive, stroke-induced encephalopathy requires an entirely different regimen than a comparatively compromised individual with Alzheimer’s disease or frontotemporal dementia. Early detection of dementia also is helpful for managing its cognitive and behavioral problems more effectively.¹Once a diagnosis of dementia is established, it might be behavioral symptoms and poor insight that become more worrisome to the patient’s caregivers and providers than cognitive deficits. Your task is then to apply behavioral approaches to management, with consistency, to maximize, at all times, the patient’s safety and comfort.⁴

How you approach behavioral management is important
Consider these interventions:

• Ensure that you appropriately treat associated depression, pain, and somatic illness—whether related or unrelated to dementia.
• Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.
• Provide family and caregivers with disease education, social support, and management tips^1,2; be respectful to family members in all interactions.³
• Offer caregivers and staff a plan for attending to supportive measures, including nutrition, hydration, and socialization.

Minimize psychosocial and environmental stressors

• Avoid unnecessary environmental changes, such as rearranging or refurbishing the patient’s living space.¹
• As noted, ensure that the patient is comfortable and safe in his (her) surroundings, such as providing wall-mounted handrails and other aids for ambulation.
• Provide access to television, proper lighting, and other indicated life-enhancing devices.^1,2
• Consider a pet for the patient; pets can be an important adjunct in providing comfort.
• Provide music to reduce agitation and anxiety.⁴
• Appeal to institutional administration to provide a higher staff−patient ratio for comfort and security.^2,5
• Because social contact is helpful to build a pleasant environment, preserve opportunities for the patient to communicate with others, and facilitate socialization by encouraging friendly interactions.¹
• Provide stimulation and diversion with social activities, support programs, and physical exercise—sources of interaction that can promote health and improve sleep.
• Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.^2,5
• Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.¹
• Provide access to television, proper lighting, and other indicated life-enhancing devices.Provide music to reduce agitation and anxiety.Redirection and validation are helpful to divert a patient’s attention from stressful situations and keep him (her) calm.Pharmacotherapy should be implemented if psychosocial methods of behavioral management fail or the patient’s behavior becomes threatening.

Other considerations

• Identify and treat primary and secondary causes of the underlying major neurocognitive disorder.
• Use an integrative, multidisciplinary approach to manage behavioral problems in dementia.
• Utilize a social worker’s expertise to faciliate family, financial, or related social issues and better cooperation. This promotes comfort for patients, families, and staff.
• Physical therapy aids in maintaining physical function, especially preservation of gait, balance, and range of motion. Thus, with greater stability avoiding a fall can be a life-saving event.
• Socialization, mental outlook, and emotional health are improved by occupational therapist interventions.
• Individual psychotherapy helps to improve self-esteem and personal adjustment. Group activities reinforces interpersonal connections.
• Refer the family and caregivers for supportive therapy and education on dementia; such resources help minimize deleterious effects of the patient’s behavioral problems on those key people.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.