Non-pharmacologic interventions for dementia management include activities, environmental modifications, and sensory therapies. While studies on their effectiveness have small sample sizes and varying methods, some interventions like music therapy and bright light therapy have shown benefits for cognition, mood, and behavior. More research is still needed, but non-pharmacologic approaches can be considered due to their safety, low cost, and potential for improving symptoms alone or as an adjunct to medication.

1. Non-pharmacologic management
of dementia
Marc Evans M. Abat, MD, FPCP,
FPCGM
Internal Medicine-Geriatric Medicine
Clinical Associate Professor, PGH
Visiting Consultant, Manila Doctors Hospital
Director, Center for Healthy Aging,
The Medical City

3. Side Effects of Cholinesterase
Inhibitors
• total number of patients who suffered at
least one adverse event before the end of
treatment
• significant differences in favor of placebo
• OR 2.51 95%CI 2.14 to 2.95, p<0.00001
Cochrane Database of Systematic Reviews
2006, Issue 1. Art. No.: CD005593. DOI:
10.1002/14651858.CD005593

4. Abdominal pain OR 1.95 95%CI 1.46 to 2.61 p<0.00001 7 studies
Abnormal dreams OR 5.38 95%CI 1.34 to 21.55 p=0.02 1 study
Anorexia OR 3.75 95%CI 2.89 to 4.87 p<0.00001 10 studies
Asthenia OR 2.47 95%CI 1.27 to 4.81 p=0.008 3 studies
Diarrhea OR 1.91 95%CI 1.59 to 2.30 p=<0.00001 13 studies
Dizziness OR 1.99 95%CI 1.64 to 2.42 p<0.00001 12 studies
Fatigue OR 4.39 95%CI 1.21 to 15.85 p=0.02 1 study
Headache OR 1.56 95%CI 1.27 to 1.91 p<0.0001 9 studies
Insomnia OR 1.49 95%CI 1.12 to 2.00 p=0.007 7 studies
Muscle cramp OR 13.32 95%CI 1.71 to 103.74 p=0.01 1 study
Nausea OR 4.87 95%CI 4.13 to 5.74 p<0.00001 13 studies
Peripheral edema OR 2.08 95%CI 1.01 to 4.28 p=0.05 1 study
Syncope OR 1.90 95%CI 1.09 to 3.33 p=0.02 5 studies
Tremor OR 6.82 95%CI 1.99 to 23.37 p=0.002 2 studies
Vertigo OR 3.95 95%CI 1.08 to 14.46 p=0.04 1 study
Vomiting OR 4.82 95%CI 3.91 to 5.94 p<0.00001 11 studies
Weight loss OR 2.99 95%CI 1.89 to 4.75 p<0.00001 4 studies
Cochrane Database of Systematic Reviews
2006, Issue 1. Art. No.: CD005593. DOI: 10.1002/14651858.CD005593

5. • Cost of treatment with ChEI, e.g. donepezil
10 mg per day
P192 per tab x 1 tab per day x 30 days =
P5760/month
Add this to:
Cost of living,
cost of other
medications
and treatment

6. Activities of Daily Living
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7. Non-pharmacologic Interventions
Sensory Enhancement Social Contact
or Relaxation • Pets
• Massage/touch • One-on-one
• Music interaction
• White noise • Simulated interaction,
• Aromatherapy family videos
• Multisensory
modalities, e.g.
Snoezelen

8. Behavior Therapy Structured Activities
• Differential • Arts and crafts
Reinforcement • Group exercises and
• Stimulus Control singing
• Outdoor walks
Cognitive Therapy
Environmental Intervention
Staff Training
• Stimulus control including
Wandering prevention
• Natural/enhanced
environment
• Reduced stimulation

9. Medical/Nursing Interventions
• Bright light therapy
• Sleep intervention
• Hearing aids
• Removal of restraints

10. Cognitive Rehabilitation and Training
• effectiveness and impact of cognitive
training and cognitive rehabilitation
– improving memory and other aspects of
cognitive functioning
– early stages of Alzheimer’s disease or
vascular dementia
• 9 trials included in the review, up to 24
weeks duration of intervention
• No significant positive or negative effects
Cochrane Database of Systematic Reviews 2003, Issue 4.
Art.No.: CD003260. DOI: 10.1002/14651858.CD003260

11. Cochrane Database of Systematic Reviews 2003, Issue 4.
Art.No.: CD003260. DOI: 10.1002/14651858.CD003260

12. Reminiscence Therapy
• four trials with a total of 144 participants had
extractable data
• significant for cognition and mood (at follow-up)
and on a measure of general behavioural
function (at the end of the intervention period)
vs. no treatment and social contact control
• significant decrease in caregiver strain
• staff knowledge of group members’ backgrounds
improved significantly
• No harmful effects
• Need for more robust studies
Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.:
CD001120. DOI: 10.1002/14651858.CD001120.pub2.

13. Massage and Touch Therapy

14. • Massage and Touch Therapy
Am J Geria Psych 2001; 9:361–381

15. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.:
CD004989. DOI: 10.1002/14651858.CD004989.pub2.

16. Music Therapy

17. • 59 with moderate-to-severe dementia were
enrolled in this study.
• Randomly assigned; 30 MT sessions (16 wk of
treatment); control group received educational
support or entertainment activities
• NPI total score significantly decreased in the
experimental group at 8th, 16th, and 20th weeks
(P=0.002).
• Specific BPSD significantly improved.
• empathetic relationship and the patients' active
participation in the MT approach, also improved
in the experimental group
Alzheimer Dis Assoc Disord. 2008 Apr-Jun;22(2):158-62

18. • 5 studies included for review
• Poor quality with heterogenous results
• All report favorable outcomes of music on
behavior (e.g. wandering), cognitive
function and emotional/social functioning
Cochrane Database of Systematic Reviews 2003, Issue 4. Art.
No.: CD003477. DOI: 10.1002/14651858.CD003477.pub2.

19. • Music Therapy
Am J Geria Psych 2001; 9:361–381

20. Other Sensory Modalities

22. • Other sensory modalities
Am J Geria Psych 2001; 9:361–381

23. Health Technol Assess 2006;10(26).

24. • Ballard 2002 in an RCT: 10% Lemon Balm in
grapeseed soil and base lotion applied topically
to arms and face twice daily for 1-2 minutes for 4
weeks vs sunflower oil applied in the same way
• 72 people with severe dementia, diagnosed with
the Clinical Dementia Rating scale (Hughes
1982) and clinically significant agitation
• Improved aggressive and non-aggressive
behavior on CMAI, NPI and DCM
Cochrane Database of Systematic Reviews 2003, Issue 3. Art.
No.: CD003150. DOI: 10.1002/14651858.CD003150.

25. Pets

26. • Pets
Am J Geria Psych 2001; 9:361–381

27. One-on-one Interaction

28. • One-on-one interaction
Am J Geria Psych 2001; 9:361–381

29. • Simulated Interaction, Family videos
Am J Geria Psych 2001; 9:361–381

30. Stimulus Control including
Wandering Prevention

31. • Stimulus control including wandering prevention
Am J Geria Psych 2001; 9:361–381

32. Staff
Training

33. • Staff Training
Am J Geria Psych 2001; 9:361–381

34. Structured
Activities

36. • Structured activities
Am J Geria Psych 2001; 9:361–381

37. Outdoor walks and Physical Activities

38. • Randomized, controlled trial, ITT analysis
of 134 ambulatory patients with mild to
severe AD.
• Collective exercise program (1 hour, twice
weekly of walk, strength, balance, and
flexibility training) vs routine medical care
for 12 months
• slower ADL decline than in exercise vs.
routine medical care (12-month mean
treatment differences: ADL=0.39, P=.02).
No adverse effects of exercise occurred.
J Am Geriatr Soc. 2007 Feb;55(2):158-65

39. • Outdoor walks and other physical activities
Am J Geria Psych 2001; 9:361–381

40. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.:
CD006489. DOI:10.1002/14651858.CD006489.pub2.

41. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.:
CD006489. DOI:10.1002/14651858.CD006489.pub2.

42. Environmental Interventions

45. • Environmental interventions
Am J Geria Psych 2001; 9:361–381

46. Bright Light
Therapy and
Sleep
Interventions

47. • Bright light therapy and sleep interventions
Am J Geria Psych 2001; 9:361–381

48. Rivastigmine Trial
6-12 mg
1-4 mg
Placebo
Dim
Light Therapy Trial
Bright
-1 0 1 2 3 4
MMSE
International Journal of Geriatric Psychopharmacology, 1, 55-65.
Biological Psychiatry, 50, 725-727.

49. JAMA. 2008;299(22):2642-2655

50. Hearing Aids and Restraint Removal

51. • Hearing aids and removal of restraints
Am J Geria Psych 2001; 9:361–381

52. Why the paucity of “solid” evidence?
• Difference in populations and available
resources
• Differences in protocols
• Differences in assessment of outcomes
• Inherent nature of the
intervention-”blinding” not feasible
• Interaction of the intervention with external
factors

53. Then why should we consider non-
pharmacologic interventions?
• Relative devoid of side effects
• Relatively cheaper
• Most, if not all, of the small studies were
done on patients already on usual care
– Cholinesterase inhibitors
– Antipsychotics and sedatives
– Medical care
Any positive effects, no matter how small the sample size, is
most likely due to the non-pharmacologic intervention

54. Zgola’s 7 W’s of a
Functional Evaluation
• What can the client do?
• What does the client do?
• How does he or she do it?
• Which parts of the task is the client
unable to do? and Why?
• Where or when does he or she
perform best?

55. Features of a
Successful Activity
• Simplicity
• Time-frame
• Distractibility
• Creativity
• Purposeful and adult like
• Scheduling

56. Summary
• Several non-pharmacologic interventions are
available for management of dementia
• Studies regarding their efficiency are available;
however, they are small and heterogenous
• The field of study is still open for more rigorous
protocols
• In the meantime, non-pharmacologic
interventions can be used because of some
degree of effectiveness, lack of side effects and
affordability