Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia - A systematic review

Background: Recent reports documenting limited evidence supporting the use of pharmacological interventions for neuropsychiatric symptoms (NPS) and increased risk of death, the black box warnings against the use of atypical antipsychotic drugs in older adults, and Omnibus Budget Reconciliation Act regulations suggest the need to evaluate the usefulness of nonpharmacological interventions in the management of NPS of dementia. Methods: To determine the evidence base of nonpharmacological interventions for the management of NPS in patients with dementia, we reviewed MEDLINE, PsycINFO, the Cochrane library, and relevant bibliographies published from January 1966 to December 2005, using the American Psychological Association Guidelines. Results: Three randomized controlled trials (RCTs) and 6 single-case designs (SCDs; N of 1 trials) met inclusion criteria. Under unmet needs interventions, 1 SCD found a moderate reduction in problem behaviors. Under behavioral interventions, based on observational data, all 4 SCDs reported a relative reduction of 50% to 100% in neuropsychiatric symptoms. Under caregiving interventions, there were 3 RCTs. At the 6-month follow-up, 1 RCT found a reduction in 4 neuropsychiatric symptom subscales: ideation disturbance score (0.3 vs 0.5; range, 0-8; P= .005); irritability score (18.8 vs 23.0; range, 8-38; P= .008); verbal agitation, as measured by mean frequency of 20-minute outbursts (0.5 vs 0.8; P=. 005); and physical aggression score (11.4 vs 12.9; range, 6- 42; P <. 001). Another RCT found a significant improvement in frequency (2.3 vs 3.1; range, 0- 4; P <. 001) and severity (2.2 vs 2.8; range, 0-4; P <. 001) of target behaviors associated with the intervention arm. The third RCT found no effect. Under bright light therapy, 1 SCD found short-term improvements on the Agitated Behavior Rating Scale (9.7 vs 19.9; P <. 001). Conclusions: The cumulative research to date on the impact of nonpharmacologic interventions for NPS among patients with dementia indicates that interventions that address behavioral issues and unmet needs and that include caregivers or bright light therapy may be efficacious. More high-quality research is necessary to confirm these findings.