Most people think of dementia as affecting memory and cognition, and it certainly does. But some of the most distressing symptoms of Alzheimer’s or other dementias are behavioral and psychological.

“What takes a lot of families by surprise are the things like agitation, problems sleeping, getting up and wandering; sometimes people even become violent,” said Dr. Keith Fargo, director of scientific programs and outreach for the Alzheimer’s Association.

Some people exhibiting these kinds of behaviors have been treated with anti-psychotic drugs, which has sparked widespread criticism. And the Food and Drug Administration (FDA) has mandated a black box warning on such drugs with older adults with dementia; they are associated with an increased risk of death.

But there’s an alternative.

“A lot of these [behaviors] can be managed with interventions that are really behavioral in nature, that do not require medication,” Fargo said. Those interventions include reminiscence therapy, music and art therapy, aromatherapy and pet therapy.

New Recommendations for Dementia Care

The use of person-centered, non-drug treatments for people with dementia is one of 56 new dementia care practice recommendations issued in late January by the Alzheimer’s Association.

They are “aimed at helping nursing homes, assisted-living facilities and other long-term care and community care providers deliver optimal quality, person-centered care for those living with Alzheimer’s and other dementias,” according to a statement by the Gerontological Society of America (GSA). The recommendations can be found online here and will be published as a supplement to The Gerontologist, the GSA’s peer-reviewed journal.

Responding to Their Environment

Sheryl Zimmerman, a professor and gerontologist at the University of North Carolina at Chapel Hill, was one of three authors of The Gerontologist’s article on non-drug practices for people with dementia.

She said the behavioral and psychological symptoms that often accompany dementia aren’t just a product of the dementia-affected brain. “Some of those behaviors are due to the interplay of the person with the environment,” Zimmerman noted.

For example: things may be happening too quickly, which can be frightening. There may be a high level of noise or too much stimulation.

Negative reactions may be exacerbated by the typical losses of aging: “An individual who has trouble seeing, for example, may be easily startled and distressed by noises that are not clearly identifiable, leading to anxiety or agitation,” the study said.

But employing non-drug therapies can help the person with dementia have a better quality of life and allow caregivers to do their job. “And it avoids the potential likelihood of giving the person (with dementia) a medication that would sedate them,” Zimmerman said.

Evidence for Non-Drug Therapies

Zimmerman and her colleagues examined 197 articles describing scientific evidence on non-drug practices to treat behavioral and psychological symptoms of dementia.

They fell into these categories: sensory practices (aromatherapy, massage, multi-sensory stimulation and bright light therapy), psychosocial practices (validation therapy, reminiscence therapy, music therapy, pet therapy and meaningful activities), and what are known as “structured care protocols” (particular procedures for bathing and mouth care).

Some of what they found:

Aromatherapy

A number of studies have looked at the use of aromatherapy for agitation and aggression in people with dementia.

Overall conclusion: Mixed results. The positive outcomes with some patients may have been because they enjoyed the interpersonal and physical benefits of having cream rubbed into their hands, the study said. More large-scale trials are needed.

Massage

“Through tactile connection, a person living with dementia may feel comforted and cared about, especially in residential care environments where touch tends to be instrumental and task specific,” the study said. Massage may also be successful in combating the social isolation that can contribute to negative behaviors. And it may spur the body’s production of oxytocin, which can infuse a sense of reassurance and calm.

Overall conclusion: A “small evidence base” shows positive results in the immediate or short term. However, some people dislike massage; that may increase agitation for them. As with any therapy, success depends on whether it’s right for the person being treated.

Bright Light Therapy

Normal aging can prompt sleep disturbances. Dementia can further disrupt a person’s circadian rhythm, resulting in agitation and “sundowning,” an increase in confusion, irritability and moodiness as the day wanes.

Bright light therapy consists of using a special light fixture, light box or visor, or exposure to natural bright light.

Overall conclusion: Mixed results. It may have some benefit, but further research is required. Some studies found it may actually make agitation worse.

Pet Therapy

Pets, particularly dogs, have been used for people with dementia for decades. “Physiologically, quiet interaction with an animal can help lower blood pressure and increase production of neurochemicals associated with relaxation and bonding,” which may in turn reduce the behavioral and psychological symptoms of dementia, the study said.

In small studies, pet therapy has succeeded in reducing disruptive behavior and increasing interactions with others.

Overall conclusion: There is a “small and preliminary” evidence base for pet therapy, even when the pet is a robotic cat or dog. Understandably, pet therapy would not work well for people who are allergic or who have had bad experiences with animals in the past.

Bathing

Bath or shower time can be particularly upsetting for a person with dementia. It is “the personal care task associated with the highest frequency of behavioral expressions of distress for persons living with dementia,” the study said. Its intimate nature may cause embarrassment, especially if the person being bathed does not recognize the caregiver and does not understand what is going on.

“Years ago, in nursing homes, people used to be hosed down, if you will,” Zimmerman said. Through a protocol called “Bathing without a Battle,” developed at the University of North Carolina at Chapel Hill, those with dementia exhibit far less agitation and resistance.

Overall conclusion: Studies have shown positive results through relatively simple changes such as sponge baths in bed and creating a “spa-like” environment with music or calming sounds. More high-quality studies are needed for the best evidence, the report said.

Each One an Individual

The bottom line, researchers and advocates said, is that everyone is different. Like any older adult, individuals with dementia have their own preferences about their surroundings, their activities and their medical treatments. That’s the basis of person-centered care.

Most of the non-drug interventions have little potential downside. But it’s important to have guidelines, and those guidelines should be based on evidence, Fargo said.

“That’s why we undertook this effort to do a review of the literature, to find out what kinds of care have the evidence base behind it. And it’s important that we disseminate that to the community,” he said.