When Medications Don’t Work:
The Importance of Using a Non-Pharmacologic Approach in Patients Suffering From Dementia With Behavior Disturbance

Dementia is an umbrella term, which covers 85-90 different conditions. Dementia causes cognitive impairment and negatively affects the functional status of the patient. There are approximately 10 million new cases diagnosed annually (Shih, Concannon, Liu, & Friedman, 2014). Following are four truths about dementia:

• At least two parts of the brain are actively dying.
• Most dementia is chronic, some occur acutely such as in a stroke.
• Most dementia is progressive and will get worse. Traumatic Brain Injuries (TBI) may be static and some are even reversible such as in dementia of depression.
• Dementia is the 5th leading cause of death.

There are many strategies to improve the quality of life of dementia patients. One of them is the use of pharmacologic intervention. Pharmacologic treatments used to control dementia with behaviors have modest efficacy at best, are associated with notable risks, and do not address the behaviors most distressing for the patient or the staff (Shih et al., 2014). Therefore, non-pharmacologic options are recommended as first-line treatments or if necessary, in parallel with pharmacologic or other treatment options (Cabrera et al., 2014; Gitlin, Kales, & Lyketsos, 2012; Shih et al., 2014). Non-pharmacologic therapies may include a general approach (problem-solving, communication and task simplification skills, etc.), or a targeted approach in which precipitating conditions of a specific behavior are identified and modified (implementing nighttime routines to address sleep disturbances).

The direct care staff are an essential piece to creating treatment strategies, gathering reliable information, and assisting in creating appropriate non-pharmacological interventions. The literature suggests that the most common plan for psychological and behavioral symptoms (repetitive speech, wandering, sleep disturbances, aggressive behavior, depression, etc.) of dementia patients were not necessarily specific therapies but working with direct care staff to modify their own attitudes and belief in order to change the behavior of those in their care (Cabrera et al., 2014; Gitlin et al., 2012).

If these behaviors are left untreated, they can contribute to more rapid disease progression, quality of life decline, accelerated functional decline, direct care staff distress, and higher health care utilization and costs (Cabrera et al., 2014; Shih et al., 2014).

Creating a care plan that focuses on non-pharmacological interventions is regarded as best practice as the first-line management for many patients living with dementia. Non-pharmacological interventions can greatly improve the quality of life and satisfaction of patients with dementia and the staff caring for them.

It’s all about trial and error!!!

Selecting a non-pharmacological approach is just the beginning. Keep in mind that any chosen plan follows the “one-third” rule:

• 1/3 The plan may work
• 1/3 May have a modest response to the plan
• 1/3 The plan may not work at all

To make things even more complicated, a plan that works today, may not work tomorrow, or, even an hour from now.

Furthermore, some strategies that are effective when implemented by one direct care staff may not work for another. These are the realities when working with dementia residents, so it is vital for the team to foster a mindset of “let’s try this and see what happens” and always have a backup approach. Try another day again. Pay attention to what a “successful” direct care staff is doing and saying. Within his or her accomplishment lies essential information that can be shared with other team members.

Dr. Tiney Ray is a MediTelecare Nurse Practitioner and Medication Manager and is also a PAC (Positive Approach to Care) Dementia Behavior Health Consultant.

1. Cabrera, E., Sutcliffe, C., Verbeek, H., Saks, K., Soto-Martin, M., Meyer, G., … Zabalegui, A. (2014). Non-pharmacological interventions as a best practice strategy in people with dementia living in nursing homes. A systematic review. European Geriatric Medicine, 1–17. http://dx.doi.org/10.1016/j.eurger.2014.06.003
2. Gitlin, L. N., Kales, H. C., & Lyketsos, C. G. (2012). Managing behavioral symptoms in dementia using nonpharmacologic approaches: An overview. JAMA, 308(19), 2020–2029. http://dx.doi.org/10.1001/jama.2012.36918.
3. Shih, R. A., Concannon, T. W., Liu, J. L., & Friedman, E. M. (2014). Improving dementia long-term care a policy blueprint [Policy brief]. Boston, MA: RAND Corporation.