Health care ­providers should consider nondrug approaches first in the treatment of patients with dementia, according to a report published March 2 online ahead of print in BMJ. 

The most effective approach is training caregivers in behavioral and environmental interventions to alleviate common symptoms of the condition, such as irritability, agitation, depression, anxiety, sleep problems, aggression, apathy, and delusions, according to Helen C. Kales, MD, and colleagues.

The researchers evaluated two decades’ of research to find five approaches that helped address behavioral issues in patients with dementia: Providing education for the caregiver; developing effective communication between the caregiver and the person with dementia; creating meaningful activities for the person with dementia; simplifying tasks and establishing structured routines; and ensuring safety and providing a better and simpler environment for the patient in the home or nursing or assisted-living setting.

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The authors offered the following framework they call DICE that health care providers and caregivers can use to tailor their approach to dementia symptoms as they change: 

Describe — Ask the caregiver and person with dementia, if possible, to describe the “who, what, when, and where” of situations in which problem behaviors occur and the physical and social context for them. Caregivers should share these details with health care providers during visits.

Investigate — The health care provider comprehensively assesses the patient’s health, dementia symptoms, current medications, and sleep habits for how they might be combining with physical, social, and caregiver-related factors to produce the behavior. 

Create — The caregiver and health care provider should work together to develop a plan to prevent and respond to behavioral issues in the patient, from enhancing the patient’s activities and environment to educating and supporting the caregiver.

Evaluate — The provider assesses how well the plan is being followed and working and determines what might need to be changed.

“The evidence for nonpharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics and far better than for other classes of medication,” Dr. Kales said.

“Drugs still have their place, especially for the management of acute situations where the safety of the person with dementia or family caregiver may be at risk.”