Behavioral Interventions for Patients With Dementia in Long-Term Care

When treating patients with dementia, behavioral approaches should usually be the first step in reducing behavioral disturbances. Nurses, social workers, activities therapists, and psychologists, for the most part, understand this point better than physicians do. Physicians may be too quick to prescribe medications to manage distressing or disruptive behaviors.

When patients with dementia display such behaviors, we must try to understand what specific needs underlie these behaviors. I think the proper mindset is, What are patients trying to tell us? Are they in pain? Are they scared? Is it too noisy? Is it too hot? Is it too cold? Is the behavior related to an old routine at this time of day? What unmet need is being expressed?

Is a patient upset because his daughter’s in Florida for the winter, and he doesn’t understand why he hasn’t seen her? Is the patient scared or angry, and, if so, about what? Is the patient having trouble hearing or seeing? Is the patient medically ill? A fundamental principle of geriatrics care is to evaluate possible medical or other reasons for behavioral problems. To me, the satisfaction of practicing geriatric medicine is the opportunity to play Sherlock Holmes under circumstances like this and try to figure out what it is that’s wrong and try to address it in a specific way rather than reaching for the prescription pad.

A December 2014 NPR story described a Minnesota nursing home facility that was able to eliminate the off-label use of antipsychotic agents for problematic behaviors by enacting a program of behavioral interventions . Tools include validation, redirecting, pet therapy, aromatherapy, massage, and white noise, as well as playing old music and providing activities that dispel boredom, such as balloon “volleyball.” A 2013 New Yorker article described a facility in Phoenix that also uses this type of individualized approach for patients with dementia so that no off-label antipsychotics are used. The atmosphere is relatively peaceful because people’s needs are addressed, focusing on their comfort in particular. Snacks are wheeled around during the day because patients may forget to eat and then not ask for food when they get hungry. Televisions are usually turned off because many shows can upset patients and distract the staff. Patients’ schedules are not dictated. Patients are allowed to continue habits from their careers, such as walking around as if working in retail or looking in staff members’ mouths as if back in the dentist’s office. Family members and staff are encouraged to accept rather than correct patients’ mistaken ideas. For example, if I’m somebody with dementia asking over and over again where my deceased wife is, and I get upset about it repeatedly, you might say to me, “Well, she may be back later. Let’s have a bowl of ice cream,” and I might very well be content with that.

Medications shouldn’t be the starting point for managing behavioral problems, except in emergencies. Behavioral interventions should be used to identify the source of problems and address them.

Financial disclosure:Dr Tariot is a consultant for Abbott, AbbVie, AC Immune, Boehringer Ingelheim, California Pacific Medical Center, Chase, CME Inc, Corium, GliaCure, Lundbeck, Medavante, Otsuka, and Sanofi-Aventis; both is a consultant for and has received research support from AstraZeneca, Avanir, Bristol-Myers Squibb, Cognoptix, Janssen, Merck, and Roche; has received research support only from Baxter Healthcare, Functional Neuromodulation, GE, Genentech, Novartis, Pfizer, and Targacept; has received other research support from NIA and AZ Department of Health Services; is a stock shareholder of Adamas; and is a contributor to a patent owned by the University of Rochester, “Biomarkers of Alzheimer’s Disease.”