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Non-Pharmacological Approaches to Address Behaviors

This section of the Toolkit contains a literature review on non-pharmacological approaches (NPA) most effective in reducing the behavioral and psychological symptoms of distress (BPSD) exhibited by persons with dementia residing in nursing homes. NPA are the first-line therapy for responding to BPSD due to the high risks and limited effectiveness of antipsychotic medications for treating these symptoms. As a result, there is an urgent need to equip nursing home providers with readily accessible tools for identifying and implementing NPA.

After presenting information that will help staff understand BPSD, practical guidance for providers, lessons learned from the field (i.e., direct care staff focus group findings), and descriptions of clinical decision support approaches are provided.

Realizing the challenges nursing home providers encounter when faced with the realities of responding to BPSD in a resource-challenged environment, experts are increasingly calling attention to the need to address both the feasibility and efficacy of NPA in nursing home settings. Among the common resource challenges faced by nursing home providers are limited access to staff with advanced training in dementia care, limited resources and high rates of turnover. The goal of this guide is to assist nursing home providers in identifying the optimal evidence-feasibility fit for their residents and facility. Feasibility was defined here using Seitz and colleagues’ guidelines[1]: high-feasibility approaches require fewer resources, lower-cost supplies, less complex activities, minimal staff training, and less need for additional personnel and less specialized personnel.

To help providers overcome some of these challenges, two tables are provided: Table 1 presents a succinct review of the evidence for different NPA; Table 2 offers practical guidance for providers, integrating both the efficacy and feasibility of different NPA. While the evidence in support of NPA may seem weak when assessed using criteria that conform to the elements of randomized clinical trials, many of these criteria (blinding and random assignment, for example) are not possible in studies that test efficacy given the nature of NPA. The evidence in Table 1 should be interpreted in light of the limitations of available systematic reviews of NPA where the selection of studies for inclusion may be very small and the criteria for assessment more appropriate for pharmaceutical trials.

Practical Guidance for Nursing Home Providers

In addition to being effective, NPA should also be feasible. Nursing homes have multiple barriers to implementing practice change.[7]To assist nursing home providers in choosing which NPA to implement, Table 2 lists specific NPA identified during a review of extant evidence and includes those approaches that demonstrated both efficacy and feasibility. An approach was considered to be more feasible if it required fewer resources, lower-cost supplies, less complex activities, minimal staff training, and less need for additional or specialized personnel. In most nursing home settings, feasibility is centrally important for the sustainability of a given approach.

Critical considerations in implementing non pharmacologic approaches: Lessons from our focus groups with direct care providers.

Regardless of the specific NPA selected for use in addressing the resident’s BPSD, several considerations should be kept in mind.

1. Human behaviors are a dynamic, moving target.
   All of us have good days and bad days. Fluctuations in mood and behavior are a normal part of human functioning. For persons living with dementia, these fluctuations can be even more exaggerated. In our focus groups direct care providers eloquently expressed their awareness of these fluctuations in acknowledging that sometimes it is really hard to pinpoint what may “set someone off” on any given day. If you follow all the guidance and direction provided by this toolkit, you may still be stymied on what is causing a given resident’s distress in a specific moment in time.


2. It’s all about trial and error.
   There is no magic bullet. Selecting a given approach to trial with a given resident with BPSD is only the beginning of the process. Though this toolkit has delineated the best and most feasible evidence based approaches for you, keep in mind that any given approach follows the “one-third” rule. A given approach may work for about a third of persons immediately; while with another third it will be only moderately successful, and the final third will not respond at all. To make things even more complex, as the direct care providers noted in our discussions, an approach that works today, may not work tomorrow, or, even an hour from now. Furthermore, some approaches that are effective when implemented by one direct caregiver may not work when implemented by another. These realities have several implications:
   • Foster a mind set of “let’s try this and see what happens”
   • Always have a backup approach if a given approach is not successful
   • One trial of an approach may not be sufficient. Try again another day.
   • Interview and observe what a “successful” direct provider is doing and saying. Within his or her success lies important information that can be shared with others.


3. Individualizing the approach to a given person is critical to success.
   Many research reviews have stressed that the more individualized or tailored an approach is, the more likely it will be that it will succeed. Direct care providers describe the process of getting to know an individual’s preferences as the secret to success in preventing or ameliorating the BPSD. They also articulate feeling hampered by knowing very little about an individual new to a facility. The flow of information from family member to direct care staff is often not a linear process, hampering the direct care workers ability to provide person centered care.

   Effective evidence-based tools are designed to help facilitate collecting and sharing this information. The first is collected upon admission via the 16 items from the MDS 3.0 Section F Customary Routine. Collecting and sharing this information with direct care staff within the first 24 to 48 hours of admission can be an effective way of closing the individualized knowledge gap. The second tool is the Preferences for Everyday Living Inventory (PELI) (see System Integration section of Toolkit).[8] The PELI is designed to provide a comprehensive overview of the daily preferences, providing more detail beyond the items included in the MDS 3.0 Section F. Recently, the MDS Section F items have been incorporated into an Advancing Excellence Campaign Person Centered Care (PCC) quality improvement tool that allows providers to track whether or not a given resident’s preferences are being honored to his or her satisfaction. This PCC tool allows providers to see “at a glance” which resident preferences are not being met. Targeting these unmet preferences is one strategy for selecting a particular approach to address that individual’s distress in experiencing BPSD.[8,9]



4. Involve the direct care worker in the interdisciplinary care planning team.
   Interdisciplinary teams are the optimal venue for selecting a particular approach for a given resident. Too often these teams do not include the direct care worker. While logistical difficulties abound in facilitating participation by direct care workers, interdisciplinary teams ignore this critical team member to their peril. The direct care workers we talked with believed that the team was missing critical information by excluding them. They also believed that the care plan did not adequately reflect approaches that were useful to them in their daily care activities. Reflecting the centrality of including the direct care giver in the care planning team meetings, Advancing Excellence included this metric in their Person-Centered Care Quality indicator.[10]


5. There is a need for specific approaches to acute episodes of a given behavior.
   In addition to knowing the individual preferences of each resident, direct care staff requested information on how to initially respond to acute episodes of behaviors such as hitting, spitting, or screaming. Specifically, they requested information on “what to say” and “how to react’” in the moment. For this reason a section was added on individual behaviors that lists approaches for initial responses that help de-escalate the behavior (see Specific Behaviors in the Toolkit). Staff also indicated that the best method for staff education is live demonstration or videos that depict successful approaches vs. unsuccessful approaches. They did not feel that written information or the internet were viable options for continuing education. The Education and Leadership section of the Toolkit highlights in red those educational programs that include demonstrations and videos on how to respond to acute episodes of behavior.

Review of the Evidence for Non-pharmacologic Approaches

Several different types of non-pharmacologic approaches are reflective of theoretical frameworks about the predisposing/precipitating factors and meaning of behaviors. Among these are: sensory stimulation, environmental modification, behavioral therapy, cognitive/emotion-oriented approaches, social contact (real or simulated), caregiver training/development (see Education and Leadership Development section of the Toolkit), structured activities, clinically-oriented approaches, individualized/person-centered care, and clinical decision support approaches. Findings from systematic reviews that have evaluated the evidence for these approaches are inconsistent, due in part to reviews having different criteria for inclusion of studies. A summary of the evidence for specific non-pharmacological approaches is presented in Table 1. In addition to systematic reviews, articles related to clinical-decision support were retrieved separately. Across systematic reviews the following points were highlighted:

• All systematic reviews underscored the need for more rigorous evidence and recognized several methodological limitations of the existing evidence-base, including the small sample sizes, variability in definitions and measurement scales, and limited measurement of different components of the approaches such as social contact.[11-13]
• The effects of most NPA for BPSD are small to moderate and have only been demonstrated to last for short durations of time. However, these effects are comparable to or greater than pharmacological approaches.
• The type of approaches most consistently found to be effective were sensory stimulation approaches, including: aromatherapy, hand massage, thermal baths, and calming or preferred music.
• There are inconsistent results regarding the benefits of behavior management approaches, in which caregivers are trained to redirect problematic behavior and reward socially acceptable behavior.[14,15]
• Only one review evaluated the interventions using two criteria: efficacy and feasibility. The investigators concluded that approaches with the greatest efficacy, such as consultation from geriatric mental health clinicians, often lacked feasibility given limited resources in nursing homes.[1] Approaches with modest evidence of efficacy but low cost, such as music therapy and sensory stimulation, were deemed more feasible.
• Across studies, an individualized approach to implementation of NPA is recommended.[14] Additionally, approaches that were tailored to individual symptoms and/or client needs were consistently the most effective.[13] Individualized approaches should include assessment for possible needs being communicated via BPSD, including for relief of pain, fatigue, hunger, thirst, and boredom or overstimulation.[14]
• The most recent advance in individualized NPA is the development and testing of clinical decision-support approaches, which were not included in many of the systematic reviews (likely in part because some reviews targeted specific BPSD while clinical decision-support approaches are generally intended to assist providers in responding to a range of BPSD). The evidence-base for these approaches was reviewed separately and is outlined in Table 2.

Non-Pharmacological Approaches for BPSD

• Review of Non-pharmacologic Approaches for Treating Behavioral and Psychological Symptoms of Distress


• Efficacious and Feasible Non-pharmacological Approaches for Behavioral and Psychological Symptoms of Distress

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