Indian Journal of Private Psychiatry
Volume 13 | Issue 2 | Year 2019

Nonpharmacological Management of Dementia: A Review

Pragya Lodha1, Avinash Desousa2

1Department of Psychiatry, De Sousa Foundation, Mumbai, Maharashtra, India
2Department of Psychiatry, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Medical College, Mumbai, Maharashtra, India

Corresponding Author: Avinash Desousa, Department of Psychiatry, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Medical College, Mumbai, Maharashtra, India, Phone: +91 9820696828, e-mail:

How to cite this article Lodha P, Desousa A. Nonpharmacological Management of Dementia: A Review. Ind J Priv Psychiatry 2019;13(2):62–70.

Source of support: Nil

Conflict of interest: None


Dementia is a complex neuropsychiatric disorder that needs medical and nonpharmacological approaches for its long-term management. This review aims at providing an overview of the various nonpharmacological strategies employed in the long-term management of dementia. The paper looks at various treatment approaches like occupational therapy, methods to improve daily living, alternative medicine approaches, and various innovative approaches like animal-assisted and pet therapy. The paper also outlines various forms of psychotherapy and cognitive enhancement methods that may be used for patients and their caregivers alike. Certain general guidelines for the nonpharmacological management of dementia at home are suggested, which shall enhance the quality of life of patients with dementia.

Keywords: Dementia, Home-based management, Nonpharmacological management, Occupational therapy, Psychotherapy.


There are 50 million suffering from dementia and India houses the second most number of them with an estimated 4.1 million people as per the “Dementia India” report published by the Alzheimer’s and Related Disorders Society of India. This is expected to double by 2035.1 The onset of dementia is usually seen in 60s and increases when individual reaches in the octogenarian age. Dementia, a common and neuropsychiatric syndrome, in itself is not a specific disease/disorder. It refers to a group of symptoms caused by brain disorders.2 It is a progressive condition that affects the abilities to think, solve problems, or control emotions that brings about cognitive and personality changes with functional decline.3 Dementia may also lead to progressive memory loss. Activities of daily living (ADLs) are progressively impaired in dementia.4 Biological functions such as sleep and appetite are usually affected by dementia, as are neuromuscular functions such as gait and balance.5

Though nonpharmacological treatment (NPT) is the first line of treatment for dementia, by choice, treatment has persisted to remain pharmacological in approach. Reasons such as less investment in cost of human labor and time and quicker administration of medication have served a win over nonpharmacological management.6 The development of new drugs and their availability has received considerable attention from the media, the public, professionals, and family caregivers as well as from persons with dementia.7 However, for over a decade, research has favored the nonpharmacological interventions for management of dementia as the first line of treatment as they have been scientifically addressed and evidence of their effectiveness has been systematized.8


In an ideal scenario, dementia should be diagnosed followed by postdiagnostic counseling to provide support with coming to terms with the diagnosis. The aim of rehabilitation in dementia is to improve functioning of the individual through a holistic approach that involves psychosocial, cognitive, physical, and sensory components.9 These strategies may be implemented in a variety of settings and treatment modalities. A range of psychosocial interventions that are flexible should be developed to match the needs of the patient and the caregiver.

Cognitive problems have been the traditional focus of interest in research and management for people with dementia.10 However, present research findings have revealed a number of commonly seen noncognitive symptoms (it is important to note that there is an ongoing debate regarding the basic terminology for “noncognitive” symptoms. The term currently favored in the psychiatric literature is “behavioral and psychological symptoms of dementia,” but most of the psychology community still uses the label “challenging behavior.” Researchers have distinguished between behavioral excesses and behavioral deficits)11 that are problematic not only for the person but also for their caregivers; thus, they are relevant in relation to clinical management. The noncognitive symptoms include agitation, aggression, mood disorders and psychosis, sexual disinhibition, eating problems, and abnormal vocalizations.12 The International Psychogeriatric Association grouped these symptoms together under an umbrella term “behavioral and psychological symptoms of dementia,” abbreviated as BPSD.13 Behavioral and psychological symptoms of dementia are usually transient and often respond to simple changes in the environment or removal of aggravating factors. Behavioral and psychological symptoms of dementia involves pharmacological and nonpharmacological interventions, though a sound clinical background must identify the root cause of BPSD.14

The concerning switch from pharmacological to nonpharmacological management was born out of documented research, which outlined the substantial adverse effects like sedation, falls, extrapyramidal signs, and possibility of reduction in quality of life and possible accelerating cognitive decline in the patients.15 Though there exists no direct comparison to evidence the comparative use of pharmacological and NPT methods, the latter has shown to be beneficial in managing behavioral and psychological symptoms related to dementia.16 It has been reported that psychosocial interventions work best to reduce agitation and to improve other behavioral disturbances in people with dementia when they are personalized to reflect the individual’s background and environmental circumstances.17

According to Cohen-Mansfield, most professionals have some training in medication prescription for BPSD but are not appropriately instructed about nonpharmacological interventions or receive information about their effectiveness. As a consequence, antipsychotics drugs are frequently prescribed before alternative nonpharmacological approaches are attempted, and patients are maintained in medication for long periods, which leads to increasing morbidity and mortality. Fewer side effects have been associated with NPTs, which render them as safer line of treatment.18

Nonpharmacological treatments entail a broad spectrum of approaches that involve to work with the patient and/or their caregivers, physical, and social environments—entailing psychological, psychosocial, interpersonal, behavioral, emotional, exercise, and environmental interventions.19 The NPTs can be broadly categorized as generalized (behavior nonspecific) or targeted (behavior-specific) treatments. These approaches either directly involve the patients and/or work through another agent—usually, the care provider or physical environment.20 These approaches conceptualize behavioral symptoms in three ways viz. the following:21

These approaches generally work to modify patient and/or caregiver cognition styles, behavior patterns, environments, precipitating events, or instructing in compensatory strategy use—to reduce the risk/vulnerability of the patients and to their environment. It is widely accepted that the care environment (physical and social) and day-to-day interactions between caregivers and persons with dementia can have a considerable impact. This means that virtually all dementia care has the potential to be therapeutic.22

Nonpharmacological alternatives encompass psychotherapy, psychoeducation, and self-care. Within that, it includes a wide range of therapies such as behavior therapy, reality orientation, music therapy, validation, and the potential of interesting new alternative options such as cognitive therapy, aromatherapy, and multisensory therapies. It is crucial to know that no one therapy is used in isolation but there are several overlaps between the therapies, and thus, an eclectic approach is the best to use.23


It is crucial to consider that though NPTs are not to cure dementia in an individual but to help create effective changes that aid the management of the syndrome progression by the following:24,25


One way of categorizing the nonpharmacological methods of managing dementia can be categorizing them on the basis of nature of symptoms, which would appear like the following:26


Behavioral Therapy

It requires a period of detailed assessment in which the triggers, behaviors, and reinforcers also known as the ABC: antecedents, behaviors, and consequences are identified and their relationships are made clear to the patient. The principles of conditioning and learning theory are aimed at suppressing or eliminating challenging behaviors. More recently, positive programming methodologies have used nonaversive methods in helping to develop more functional behaviors. Overall, BMT include a wide variety of behavioral interventions such as functional analysis of specific behaviors, token economies, habit training, progressive muscle relaxation, communication training, behavioral or cognitive-behavioral therapy, and various types of individualized behavioral reinforcement strategies.27,28

Reality Orientation Therapy

It is one of the most widely used management strategies for working with people having dementia. It aims to help people with memory loss and disorientation by reminding them of facts about themselves and their environment. People with memory loss are oriented to their environment using a range of materials and activities. This involves consistent use of orientation devices such as signposts, notices, and other memory aids. Though, the efficacy of the therapy is debatable.29,30

Validation Therapy

Some of the features associated with dementia such as repetition and retreating into the past were in fact active strategies on the part of the affected individual to avoid stress, boredom, and loneliness. Validation therapists therefore attempt to communicate with individuals with dementia by empathizing with the feelings and meanings hidden behind their confused speech and behavior. It is the emotional content of what is being said that is more important than the person’s orientation to the present.31,32

Reminiscence Therapy

This involves helping a person with dementia to relive past experiences, especially those that might be positive and personally significant, for example, family holidays and weddings. This therapy can be used with groups or with individuals. Group sessions tend to use activities such as art, music, and artifacts to provide stimulation. It is seen as a way of increasing levels of well-being and providing pleasure and cognitive stimulation.33,34


Music Therapy

It may involve engagement in a musical activity (e.g., singing or playing an instrument), or merely listening to songs or music. More recently, it has been found that there is a significant reduction in agitation in people with dementia who were played an individualized program of music as opposed to traditional relaxation music. Individuals with dementia may retain the ability to sing old songs, and musical abilities appear to be preserved in some individuals despite aphasia and memory loss. Music interventions range from activities administered by a professional music therapist to the presentation of recorded music by caregivers to patients in an individual or group setting.3537

Art-based Therapy

It is a recommended treatment for people with dementia as it has the potential to provide meaningful stimulation, improve social interaction, and improve levels of self-esteem. Activities such as drawing and painting are thought to provide individuals with the opportunity for self-expression and the chance to exercise some choice in terms of the colors and themes of their creations.38,39

Activity Therapy

This involves a diverse group of recreations such as dance, sport, and drama. It has been shown that physical exercise can have a number of health benefits for people with dementia. Dance therapy, with specific dance forms/moves, involves no prescriptive steps or motions but allows the participants to engage with each other in interactive movements. It is relevant to note that this may also fulfill a need for nonsexual physical contact which many people with dementia find soothing.40,41

Complementary Therapies

A number of different therapies like massage, reflexology, Reiki, therapeutic healing, herbal medicine, and aromatherapy are also employed. In terms of effectiveness, more careful consideration is needed. In general, most of the complementary therapies have not received a great deal of empirical investigation.42,43


Acupuncture is an ancient Chinese treatment that has been used for over 3,000 years. Controlled investigations reveal that acupuncture outperforms drug therapy for the treatment of vascular dementia. Acupuncture was found both safe and effective; however, specific acupuncture protocols were found superior to conventional treatments. Multiple studies indicate that the microacupuncture system termed scalp acupuncture is particularly beneficial to vascular dementia patients. In vascular dementia, impaired blood flow deprives oxygen and nutrients to the brain; mental deterioration affects cognition, memory, language skills, emotions, and personality. The researchers cite Traditional Chinese Medicine (TCM) theory as the basis for their acupuncture protocol development.44,45


It is one of the fastest growing of all the complementary therapies. Aromatherapy consists of the use of fragrant oils from plants and has been used to promote sleep and reduce behavioral symptoms in individuals with dementia. It appears to have several advantages over the pharmacological treatments widely used for dementia. It has a positive image and its use aids interaction while providing a sensory experience. The two main essential oils used in aromatherapy for dementia are extracted from lavender and Melissa balm. There is an added advantage that there are several routes of administration such as inhalation, bathing, massage, and topical application in a cream.46

Bright-light Therapy

It has been increasingly used in an attempt to improve fluctuations in diurnal rhythms that may account for night-time disturbances and “sundown syndrome” (recurring confusion or agitation in the late afternoon or early evening) in people with dementia. Few controlled trials have been published with some evidence for improving restlessness and with particular benefit for sleep disturbances. Light stimulation also aims to improve the circadian disturbances in the sleep-wake cycles experienced by individuals with dementia.47


Multisensory Approaches

This involves using a room designed to provide several types of sensory stimulation such as light, texture, smell, and sound. The use of these resources is tailored to the individual and not all of the available forms of stimulation may be used in one session.48

Simulated Presence Therapy

Simulated presence therapy involves video or audiotape recordings of family members that are played to the person with dementia. The content of the recordings may vary depending on the interests of the individual and may include conversations, stories, or shared memories. The intention is that the recorded voice of a family member is reassuring, and that anxiety and distress are reduced by making the environment of the person with dementia as familiar as possible. Overall, well-conducted studies are lacking, the evidence that SPT reduces behavioral symptoms of dementia is inconsistent, and SPT may have adverse effects in some patients. Simulated presence therapy is sometimes referred to as simulated family presence therapy because it originated from the observation that nursing home residents who received more visits from family members were less agitated and had greater life satisfaction.49,50

Snoezelen Multisensory Stimulation Therapy

Multisensory stimulation (MSS), otherwise known as Snoezelen therapy, combines the therapeutic use of light, tactile surfaces, music, and aroma. Multisensory stimulation is based on the premise that neuropsychiatric symptoms may result from periods of sensory deprivation.51

Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation is a noninvasive analgesic technique that is most often used for pain control and occasionally for neurological and psychiatric conditions, such as drug/alcohol dependency, headaches, and depression. Although some short-lived improvements in neuropsychological symptoms of dementia have been observed with TENS, definite conclusion on the possible benefits of this intervention cannot be made.52


Physical Exercises

It has been shown that physical exercise can have a number of health benefits for people with dementia though research findings have not shown significant improvement in the symptoms of BPSD. Improvement for the caregivers as a result of physical exercises (walking, running, and dancing, etc.) has been demonstrated.53

Touch Therapy

It can include massage, craniosacral techniques, or therapeutic touch. It has been investigated through a three-blind fold study that the effect of touch therapy on BPSD has a significant effect in reducing behavioral symptoms when compared to the group without any touch intervention. Massage and touch therapies aim to reduce depression, anxiety, and other behavioral symptoms of dementia.54


Physiotherapy can help manage pain. Pain affects mental function, motivation, and affects how the person with dementia responds to any rehabilitation program. People living with dementia who have difficulty speaking will not be able to easily report pain. These people are at risk of receiving inadequate medication and treatment of pain. It is important that pain is addressed before and during therapy to allow for better rehabilitation.55


Cognitive Behavior Therapy

Over the past 10 years, there has been an increasing need to apply CBT-based therapies in care for dementia. There have been reported positive findings from a clinical trial of CBT with people in the early stages of Alzheimer’s disease. Favorable results have been obtained with individual and group CBT.56

Interpersonal Therapy

It examines the individual’s distress within an interpersonal context. It uses a specific framework in which the individual’s distress is conceptualized through either of the domains: interpersonal disputes; interpersonal/personality difficulties; bereavement; and transitions/life events. Despite there being good empirical evidence of the success of this form of treatment with older people, the use of this therapy with patients of dementia is recent.57


This entails paying closer attention to patients’ needs especially providing basic human needs like toileting, making basic personal care items reachable to the patients/residents, identifying any early sign of distress with quick/prompt intervention, identifying any communication deficits, and addressing it. Both caregivers and families must be psychoeducated about the patient’s problems and management.58


In a way, both yoga and meditation are “brain exercises” that engage different parts of the brain based on the components of practice (breathing, movement, postures, chanting, visualization, and concentration) and can help the brain form new connections and recover from injuries or to stimulate neuroplasticity. Yoga may play a role in prevention and improve symptoms and quality of life for patients and their caregivers alike. Studies have also found that yoga and meditation may aid socializing and feel better. Yoga and meditation may also help prevent dementia to an extent.59,60


Tailored activities programs (TAP) are one of occupational therapies that research has found to be effective that focuses on reducing undesirable behaviors associated with dementia. The principle of TAP is the selection of activities that are specifically tailored to the patient according to his/her abilities, interests, and roles. The program also helps caregivers to develop an increased sense of self-efficacy by offering trainings to simplify activities and help them adapt for future functional declines of the patient as well as to generalize the strategies to other contexts.61


The impact of cognitive interventions on the BPSD is still not well-known because most of studies have focused on improving global or specific cognitive functions. Considering the importance of the relationship between cognitive interventions and BPSD, research trials of cognitive programs have been evaluated to find a significant reduction of delusional symptoms with a large effect size; however, aberrant motor behavior increased significantly in the treatment condition when compared to the control group.62


The goals of group therapy include creation of an emotional climate of acceptance and warmth among the group members, which helps patients to learn to accept themselves and their feelings. There is frequent intervention by the therapist to help facilitate social interaction for patients whose communication ability is impaired. Group therapy allows an opportunity for patients to experience the feelings of being part of a group, to ventilate feelings, opportunity for them to reminisce about past accomplishments and give new meaning to their lives, and to create a platform for patients to achieve a sense of self by expressing personal opinions in an environment of respect and acceptance.63,64


The basis for using support groups as a psychosocial intervention is the assumption that when individuals who have experienced a similar traumatic event gather together to share their concerns, they can cope with the stress better than on their own. Limited data from two studies suggest that support groups may be of psychological benefit to people with dementia by reducing depression and improving quality of life and self-esteem.64 The role of support groups with respect to dementia has chiefly revolved around support groups for caregivers to relatives with dementia. Recently, the notion has been expanded to include individuals with dementia themselves. Goals include grief work, achieving balance between maintaining independence and facing dependence, responding to altered interpersonal interactions, and provision of information about the disease and community resources.65


Techniques that may be utilized in relationship counseling include focusing on one issue at a time, seeing the patient and their family separately and together, utilizing relationship as a resource, role playing, balanced focus on strengths and deficits, and collaborative stance. Role playing is a very useful technique to help the person with dementia and his or her family reduce negative statements and replace it with supportive statements that indicate kindness and compassion.3 Systematic research regarding couples and family therapy for people with dementia that could guide clinical approach is lacking.66,67


Dementia can be conceptualized in terms of social disability as well as that highlights the way in which symptoms such as memory problems—and the secondary effects of these, such as loss of confidence or negative reactions from others—affect the possible way of engaging in activities and participating in society. Activity limitation and participation restriction can be tackled from two directions, community and personal perspective. From a community perspective, the focus is on reducing external barriers by expanding awareness, changing public attitudes, and creating accessible, dementia-friendly environments. From a personal perspective, the focus is on enabling people with dementia to participate in everyday life and in their families and communities, in a way that is meaningful to them. This entails rehabilitation.68


A liaison approach is ideal for the treatment of any illness, and so for dementia. The liaison approach to manage dementia involves the following professionals in team work for an ideal outcome:69


Pharmacotherapy manages the BPSD such as aggression, irritability, screaming and laughing without reason, inappropriate sexual behaviors, hypersexuality, and other psychological symptoms (depression, anxiety, and insomnia, etc.).


Nonpharmacological therapy or psychotherapeutic intervention in the form of diverse forms of therapy, best suited to the needs of the person with dementia is provided. Therapies may be symptom-based, cognitive/behavioral or broad spectrum, traditional/brief and alternative. Psychoeducation of the condition to the family members and the patient themselves is an important element. Therapists suggest various lifestyle changes to the family members in order to accommodate for the condition of the person with dementia and offer appropriate support.

Occupational Therapist

Through their academic curricula, expertise in activity analysis, and work with older people in various settings, occupational therapists address dementia as a condition that affects occupational performance. Practitioners can educate family members, concerned others, and even those in the early stages of the disease about dementia and its functional implications. Occupational therapists evaluate persons with dementia to determine their strengths, impairments, and performance areas needing intervention. Although remediation of cognitive performance is not likely, the person may demonstrate improved function through compensation or adaptation. Occupational therapy practitioners also assist care providers to help them cope with this difficult, and yet often rewarding, role.

Medical/Primary Healthcare Professional

They manage the medical illnesses such as stroke, Parkinson’s disease, cerebrovascular diseases, anemia, and others that may be present as comorbid conditions. They also take care of the routine check-ups.


They provide with nutritional supplements that can play an adjunctive role to medical treatment, but they play a bigger role and have a larger potential when used as a preventive tool rather than a curative one. Omega-3 fatty acids, vitamin E, vitamin B6 and B12, and C along with folic acid, and curcumin have been shown to play a preventive role in the development of dementia.70


They use movement of the body to help bring about physical, psychological, and social well-being. Physiotherapy plays an important role in promoting and maintaining mobility in people with dementia as well as improving their quality of life and reducing the burden of care.

Family Members

Family members play a crucial role in managing dementia and helping in maintaining an appropriate psychosocial care for the patient.


Home-based care is a cost-effective model that is comfortable to the patients as they are in familiar surroundings. It includes both pharmacotherapy and nonpharmacological management. The carers should be properly educated about the clinical features of disease as caring for a person with dementia has been identified as a chronic stressor that places caregivers at risk for physical and emotional problems.71

Care for patients with dementia involves management with the caregivers who are a part of the first line of care. Apart from the traditional nonpharmacological means of management and psychoeducation, there are several simple to-do practices that one can follow to make home living and diurnal routines easy for patients with dementia.72


A calendar must be put in the room of the person so that he/she can be routinely reminded of the day and month. The calendar can be marked to identify a special occasion or festivity. Also, calendar with single dates that can be torn off is a practical means for the person to know the date each day.73

Tripod Stick and Walker

A tripod stick for apt balance and to reduce the chance of falling is a viable option for the person with dementia. It is well-known that “falls” are common, frequent, and can be health-risking in older ages, and preventing falls is one of the crucial aspects of care.74

Identity Card

Making the person wear an identity card with personal details such as the name, address, and contact details is a good way to ensure that if, by chance, the person loses their way to home, they can get help in crisis. If required, family members should also wear identity cards with their names so that the person with dementia can recognize the names and respective people.

Family Tree

Family members can make a family tree that can repeatedly remind the person of their family members in case their memory starts to decline. It can be placed in the person’s room or somewhere in the house which is most frequented by them.75

Less Furniture

It is best to ensure minimal furniture in the room of the person with dementia so that accidents can be avoided. People with dementia may not remember getting scratched or hurt by objects/furniture in the room. Less distance between bed and bathroom should be ensured for the comfort of the person of dementia which reduces chances of fall during night times. Also, help with toilet needs should be provided when required.

Exercise and Walk

People with dementia should be encouraged to walk or exercise for 30 minutes every day in order to prevent the raised risk of stroke and cardiac arrest (which increase with dementia as comorbid condition).

Cognitive Engagements

Cognitive engagements with people suffering from dementia can involve playing simple games like chess or board games with them. It can also involve cognitive exercises to rejuvenate the mind and work upon mental abilities that may have deteriorated, for example, attention. Restorative exercises like helping the person with dementia to relearn simple operations like using switches, changing channels on a television, or operating a microwave.76

Simplify Communication

While communicating with a person suffering from dementia, one must keep commands simple, one task at a time; allow extra time for a response to an asked question before repeating it; if the individual does not appear to understand, try rephrasing what is told to them; do not talk whilst the person is trying to perform a task; avoid multitasking and distractions; make sure communication problems are not due to problems with the persons sight or hearing and check that glasses and hearing aids are in good working order; use names and explain phrases where possible, such as your son, Abhay.77

Fix a Routine

Create a small daily routine for the person. Encourage them to do more tasks and motivate them for the same. Help them if they ask.

Assess the Home

The house should be assessed for any potential hazards that may likely hurt the person or make them trip/fall.


Animal-assisted therapy is gaining popularity as part of therapy programs in residential-aged care facilities. Humans and pet dogs, birds, and cats respond to quiet interaction with a lowering of blood pressure and an increase in neurochemicals associated with relaxation and bonding. These effects may be of benefit in ameliorating BPSD. Several small studies suggest that the presence of a dog reduces aggression and agitation, as well as promoting social behavior in people with dementia. One study has shown that aquaria in dining rooms of dementia care units stimulate residents to eat more of their meals and to gain weight but is limited by the small number of facilities studied. There is preliminary evidence that robotic pets may provide pleasure and interest to people with dementia. It is important that the animal and the therapist are trained before using animal-assisted therapy for dementia.7880


Each therapy has its advantages and disadvantages; however, the key lies in training the caregivers, professional, and family. In fact, it is a research-oriented suggestion that the most common interventions for BPSD are not necessarily specific therapies but working with carers or nursing home staff to change the attitudes and behavior of those in their care (at a home and fundamental care level). The field of dementia care is expanding. Training, management of behavioral and psychological symptoms, follow-up sessions, and implementation of treatment programs require further intensive work in order to intensify the efficacy of the nonpharmacological interventions for dementia care.81


A few suggestions for the cognitive exercises which may be woven into one’s daily routine to build resilience for dementia are the following:82


The field of dementia care is ever expanding and new therapies get added to those available in the management of dementia regularly. It is prudent that NPTs become an integral part of dementia management and rehabilitation programs. While this is important, one must always combine multiple approaches together as no one method fits the bill in the long-term management of dementia. There is also a need for a team approach in the management of patients with dementia with sound communication and planning between team members. Medical management must be aimed at synergizing with nonpharmacological management to enhance the long-term management and quality of life of patients with dementia.


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