48

Non-pharmacological Interventions

for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

APPENDIX A. Search Strategy for Non-pharmacological Treatment of Dementia, Reviews

MEDLINE (PubMed) searched on 10/08/2009

Search # Concept Search String N

1 Dementia “dementia”[MeSH Terms] OR “dementia”[All Fields] OR 

dement*[tiab] OR “mild cognitive impairment” [tiab]

110,737

2 Non-Pharmacological 

treatments

(“non pharmacologic*”[tiab] OR “non-pharmacologic*”[tiab] OR 

“nonpharmacologic*”[tiab]) AND ( therapy [tiab] OR intervention 

[tiab])

1,357

3 Psychotherapy “psychotherapy”[MeSH Terms] OR “psychotherapy”[tiab] 126,941

4 exercise/physical 

activity

“Exercise/therapy”[Mesh] OR “Exercise Therapy”[Mesh] 

OR “exercise”[tiab] OR “motor activity”[MeSH Terms] OR 

(“motor”[tiab] AND “activity”[tiab]) OR “motor activity”[tiab] OR 

(“physical”[tiab] AND “activity”[tiab]) OR “physical activity”[tiab]

281,156

5 transcutaneous 

electrical nerve 

stimulation (TENS)

“transcutaneous electrical nerve stimulation”[tiab] OR 

(“transcutaneous electric nerve stimulation”[MeSH Terms] OR 

(“transcutaneous”[tiab] AND “electric”[tiab] AND “nerve”[tiab] 

AND “stimulation”[tiab]) OR “tens”[tiab])

9,317

6 snoezelen multisensory stimulation“Snoezelen” OR “multisensory stimulation” OR “multi sensory 

stimulation” OR “multi-sensory stimulation” OR “multisensory 

environment” OR “multi sensory environment” OR “multi-sensory 

environment”

108

7 bright light therapy “phototherapy”[MeSH Terms] OR “phototherapy”[tiab] OR 

(“light”[tiab] AND “therapy”[tiab]) OR “light therapy”[tiab] OR 

“photo-therapy”[tiab] OR “light-therapy”[tiab]

31,862

8 smart home 

technologies

(Home-based[tiab] AND (assistive technologies[tiab] OR 

assistive technology[tiab])) OR smart home technologies[tiab] 

OR smart home technology[tiab] OR (“Telemetry”[Mesh] OR 

“Telemedicine”[Mesh])

16,073

9 acupuncture “acupuncture”[MeSH Terms] OR “acupuncture”[tiab] OR 

“acupuncture therapy”[MeSH Terms] 

14,240

10 massage and touch 

therapies

(“touch”[MeSH Terms] OR “touch”[tiab]) AND 

(“therapy”[Subheading] OR “therapy”[tiab] OR 

“therapeutics”[MeSH Terms] OR “therapeutics”[tiab]) OR 

“Massage”[Mesh] OR “massage” [tiab]

13,184

11 music therapy “music therapy”[MeSH Terms] OR (“music”[tiab] AND 

“therapy”[tiab]) OR “music therapy”[tiab]

1,990

12 sensory stimulation “sensory stimulation”[tiab] 1,514

13 aromatherapy “aromatherapy”[MeSH Terms] OR “aromatherapy”[tiab] OR 

(“aroma”[tiab] AND “therapy”[tiab]) OR “aroma therapy”[tiab]

590

14 reality orientation “Reality Therapy”[Mesh] OR reality orientation [tiab] OR reality 

therapy [tiab]

374

15 behavioral 

management 

(behavior* [tiab] AND management [tiab]) OR Behavior Therapy 

[MeSH]

50,249

16 simulated presence “simulated presence” [tiab] 10

17 reminiscence therapy (“reminisce” [tiab] OR “reminiscence” [tiab]) AND (“therapy” [tiab] 

OR “technique*” [tiab] OR “treatment” [tiab] OR “intervention” 

[tiab] OR “group” [tiab])

224

18 validation therapy “validation” [tiab] AND (“therapy” [tiab] OR “technique*” [tiab] OR 

“treatment” [tiab] OR “intervention” [tiab])

13,769
49

Non-pharmacological Interventions

for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

19 all treatments OR (#2-18) 506,887

20 all treatments for 

dementia

#19 AND #1 4,729

21 non-indexed articles 

from set #20

#20 AND (in process[sb] OR publisher[sb] OR 

pubmednotmedline[sb])

140

22 indexed articles from 

set #20

#20 NOT #21 4,589

23 articles indexed as 

systematic reviews

#22 AND systematic [sb] 196

24 (systematic reviews, 

or un-indexed) 

English only

(#23 OR #21) AND English[lang] 304

The symptoms, comparators, outcomes and settings are best dealt with using inclusion and exclusion criteria, 

including them in the search risks artificially limiting the search results.

PsycINFO (OVID)searched on 10/08/2009

Search # Concept Search String N

1 Dementia exp dementia/ or exp alzheimers disease/ or exp cognitive 

impairment/ or Dementia.mp.

52,506

2 Psychotherapy psychotherapy.mp. or exp Psychotherapy/ 169,679

3 exercise/physical 

activity

exp physical activity/ or exercise.mp. or physical activity.mp. 30,661

4 transcutaneous 

electrical nerve 

stimulation (TENS)

exp Electrical Stimulation/ or transcutaneous electrical nerve 

stimulation.mp. or tens.mp.

14,847

5 snoezelen multisensory stimulationsnoezelen.mp. or perceptual stimulation.mp. or exp Perceptual 

Stimulation/ or multi sensory stimulation.mp. or multi sensory 

environment.mp.

49,928

6 bright light therapy light therapy.mp. or exp Phototherapy/ 801

7 smart home 

technologies

(exp Technology/ and exp Housing/) or smart home.mp. or exp 

telemedicine/

1,122

8 acupuncture acupuncture.mp. or exp Acupuncture/ 759

9 massage and touch 

therapies

exp Massage/ or massage.mp. or exp Physical Contact/ or touch 

therapy.mp.

2,162

10 music therapy music therapy.mp. or exp Music Therapy/ 2,763

11 aromatherapy aromatherapy/ or olfactory stimulation/ or (aromatherapy or aroma 

therapy).mp.

1,1661

12 reality orientation exp Reality Therapy/ or reality orientation.mp. or reality therapy.mp. 964

13 behavioral 

management 

exp Behavior Therapy/ or exp Behavior Modification/ or behavioral 

management.mp.

34,227

14 simulated presence simulated presence.mp. 12

15 reminiscence therapy exp Reminiscence/ or reminiscence therapy.mp. 1,200

16 validation therapy validation therapy.mp. 39

17 all treatments OR (#2-16) 286,924

18 all treatments for 

dementia

#17 AND #1 2.150

19 systematic reviews limit #18 to (“0800 literature review” or “0830 systematic review” or 

1200 meta analysis)

127

20 English limit 19 to english language 120

After de-duplication with PubMed results : 102 unique citations
50

Non-pharmacological Interventions

for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

Cochrane Database of Systematic Reviews & Cochrane Database of Abstracts of Reviews of 

Effects (OVID) searched on 10/08/2009

Search # Concept Search String N

1 Dementia dementia.mp. or alzheimers.mp. or cognitive impairment.mp. 559

2 Non-Pharmacological 

treatments

non-pharmacological treatment.mp. 37

3 Psychotherapy Psychotherapy.mp. 587

4 exercise/physical 

activity

exercise.mp. or physical activity.mp. 1,750

5 transcutaneous 

electrical nerve 

stimulation (TENS)

transcutaneous electrical nerve stimulation.mp. or tens.mp. 181

6 snoezelen multisensory stimulationsnoezelen.mp. or multi sensory environment.mp. or multi-sensory 

stimulation.mp.

10

7 bright light therapy light therapy.mp. or phototherapy.mp. 0

8 smart home 

technologies

smart home.mp. or 

telemedicine.mp.

60

9 acupuncture acupuncture.mp. 1

10 massage and touch 

therapies

massage.mp. or 

touch.mp.

391

11 music therapy music therapy.mp. 78

12 sensory stimulation sensory stimulation.mp. 23

13 aromatherapy (aromatherapy or aroma therapy).mp. 45

14 reality orientation reality orientation.mp. or reality therapy.mp. 18

15 behavioral 

management 

behavioral management.mp. or behavior therapy.mp. or behavior 

modification.mp.

270

16 simulated presence simulated presence.mp. 6

17 reminiscence therapy reminiscence therapy.mp. 11

18 validation therapy validation therapy.mp. 5

19 all treatments OR (#2-18) 2,848

20 all treatments for 

dementia

#19 AND #1 158

No duplicated detected by EndNote
51

Non-pharmacological Interventions

for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

APPENDIX B. Search Strategy for Primary Studies

on Animal-assisted Therapy for Dementia

PubMed search 12/9/2009, 275 results

“humans”[MeSH Terms] AND ((((((((((pet therapy[tiab] OR animal assisted therapy[tiab]) OR 

animal therapy[tiab]) OR dog therapy[tiab]) OR dog assisted therapy[tiab]) OR animal-assisted 

activities[tiab]) OR animal-assisted interventions[tiab]) OR aquarium[tiab]) OR ((“Dogs”[Mesh] 

OR “Cats”[Mesh]) OR “Birds”[Mesh])) OR (“Bonding, Human-Pet”[Mesh] OR “Animals, 

Domestic”[Mesh])) AND (“dementia”[MeSH Terms] OR “dementia”[All Fields]))

PsycINFO search 12/9/2009, 83 results (61 unique)

PsycINFO 1806 to December Week 2 2009

# Searches Results

1 pet therapy.mp. or exp Animal Assisted Therapy/ 335

2 animal assisted therapy.mp. or exp Animal Assisted Therapy/ 330

3 animal assisted therapy.mp. 330

4 exp Interspecies Interaction/ or exp Pets/ or exp Dogs/ 5351

5 dog therapy.mp. 8

6 dog assisted therapy.mp. 3

7 animal assisted activities.mp. 18

8 animal assisted interventions.mp. 10

9 aquarium.mp. 269

10 cats.mp. or exp Cats/ 11113

11 birds.mp. or exp Birds/ 22735

12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 38995

13 dementia.mp. or exp Dementia/ 45487

14 12 and 13 83

15 from 14 keep 1-10 10

16 from 14 keep 1-83 83

CINAHL search 12/9/2009, 65 results (44 unique)

# Searches Results

S14 S12 and S13 65

S13 (“dementia”) or (MH “Dementia+”) 23,299

S12 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 3,595

S11 (“birds”) or (MH “Birds”) 926

S10 (“cats”) or (MH “Cats”) 923

S9 aquarium 20

S8 “animal assisted interventions” 7

S7 “animal assisted activities” 4

S6 (“dog assisted therapy”) or (MH “Service Animals”) 126

S5 “dog therapy” 0

S4 (“pets”) or (MH “Pets”) 1,279

S3 (“human pet bonding”) or (MH “Human-Pet Bonding”) 288

S2 “animal assisted therapy” 105

S1 (“pet therapy”) or (MH “Pet Therapy”) 526

Deduplication notes – MPF 10Dec09

Total citations after deduplication = 371
52

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

nclusion/Exclusion Criteria for Systematic Reviews of

pharmacological Interventions

 review/meta-analysis of clinical trials or 

................................................................STOP

......................................................................

east partly include patients with dementia?

................................................................STOP

......................................................................

 outpatient care setting (including home-based 

ended-care facilities)?

................................................................STOP

......................................................................

lowing behavioral symptoms: apathy, agitation, 

mpulsivity, disinhibition, depression, or 

?

................................................................STOP

......................................................................

fectiveness, safety, or cost of any of the 

ns?

......................................................................

......................................................................

......................................................................

......................................................................

......................................................................

......................................................................

......................................................................

al mgmt, cognitive stimulation or 

on, simulated presence, 

......................................................................

mulation ........................................................

cial alarms, electronic assistive devices, 

, automated home environments).................

ve Stimulation (TENS).................................

eatment, specify............................................

................................................................STOP

6. Does the comparator intervention consist of any of the following: 

another non-pharmacologic treatment, medical/ pharmacological treatment, or no treatment? Note: ECT is considered medical treatment.a. No.................................................................................................. STOPb. Yes....................................................................................................... 

7. Does the study report on any of the following patient outcomes?

Use of psychotropic drugs.......................................................................... Cognition.................................................................................................... Mood .......................................................................................................... Behavioral disturbances............................................................................. Social function ........................................................................................... Physical function........................................................................................ Hospitalizations, institutionalization, or other healthcare visits, including: ER visits..................................................................................................... Accidents.................................................................................................... Health-related quality of life ...................................................................... Satisfaction with healthcare ....................................................................... Other, specify ............................................................................................. None of the above ...................................................................Proceed to Q8

8. Is the text of the article in English?

a. No.................................................................................................. STOPb. Yes....................................................................................................... 

9. If this article meets no other criterion, should it be saved for background or 

discussion?a. No.................................................................................................. STOPb. Yes: narrative review with potentially useful references................... c. Yes: primary study, possibly more recent than existing SRs............. d. Yes: clinical guidelines ...................................................................... e. Yes: discusses methodological issues................................................ f. Yes: systematic review that did not meet all quality criteria ............. 
53

Non-pharmacological Interventions

for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

APPENDIX D. QUALITY RATING CRITERIA FOR

SYSTEMATIC REVIEWS*

Overall quality rating for each systematic review is based on the below questions. Ratings are 

summarized as: Good, Fair, or Poor:

• Search dates reported? Yes or No

• Search methods reported? Yes or No

• Comprehensive search? Yes or No

• Inclusion criteria reported? Yes or No

• Selection bias avoided? Yes or No

• Validity criteria reported? Yes or No

• Validity assessed appropriately? Yes or No

• Methods used to combine studies reported? Yes or No

• Findings combined appropriately? Yes or No

• Conclusions supported by data? Yes or No

Definitions of ratings based on above criteria

Good: Meet all criteria: Reports comprehensive and reproducible search methods and results; 

reports pre-defined criteria to select studies, and reports reasons for excluding potentially 

relevant studies; adequately evaluates quality of included studies and incorporates assessments 

of quality when synthesizing data; reports methods for synthesizing data and uses appropriate 

methods to combine data qualitatively or quantitatively; conclusions supported by the evidence 

reviewed.

Fair: Studies will be graded fair if they fail to meet one or more of the above criteria, but the 

limitations are not judged as being major.

Poor: Studies will be graded poor if they have a major limitation in one or more of the above 

criteria.

*Created from the following publications: 

Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of the 

process. Am J Prev Med. 2001:20(3S); 21-35.

National Institute for Health and Clinical Excellence. The Guidelines Manual. London: Institute for Health and 

Clinical Excellence; 2006.

Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol. 1991;44:1271-8.
54

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

nclusion/Exclusion Criteria for Pet/Animal-assisted Therapy

 controlled clinical trial? 

............................................................... STOP

..................................................................... 

_____________________________________

east partly include patients with dementia?

............................................................... STOP

..................................................................... 

 outpatient care setting (including home-based 

ended-care facilities)?

............................................................... STOP

..................................................................... 

the following behavioral symptoms: 

calizations, aggression, disturbed sleep, 

ibition, depression, inappropriate sexual 

nt hallucinations and delusions?

............................................................... STOP

..................................................................... 

fectiveness, safety, or cost of any form of 

............................................................... STOP

..................................................................... 

nsist of usual care (no treatment/intervention)?

............................................................... STOP

..................................................................... 

7. Does the study report on any of the following patient outcomes?

Use of psychotropic drugs............................................................................Cognition......................................................................................................Mood ............................................................................................................Behavioral disturbances ...............................................................................Social function..............................................................................................Physical function..........................................................................................Hospitalizations, institutionalization, ER or other healthcare visits ............Accidents......................................................................................................Health-related quality of life ........................................................................Satisfaction with healthcare .........................................................................All cause mortality .......................................................................................Other, specify ...............................................................................................None of the above .....................................................................proceed to Q8

8. Is the text of the article in English?

a. Yes........................................................................................................ 

9. If this article meets no other criterion, should it be saved for background, 

discussion, or other reasons?a. No....................................................................................................STOPb. Yes: narrative review, general description, reports of uncontrolled 

studies, informal observational studies with potentially useful references..............................................................................................

c. Yes: clinical guidelines..........................................................................d. Yes: discusses methodological issues ...................................................e. Yes: other non-pharmacological therapy, may apply to larger report....
55

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

REVIATIONS

ing scale

erapy

s in Dementia

e

living

 and Related Disorders Association

puterised diagnostic system designed

eriatric Mental State and the History

edule (designed to collect information about 

spondent with special reference to psychiatric 

mentia, and about putative aetiological 

esearch with older people. AGECAT contains 

for organic, anxiety, depression, etc.

care Research and Quality

Aging

giving Scale

ntory

nventory

Rating Scale

ogy in Alzheimer’s Disease Rating Scale

ment training

Rating Scale

 AD

ention Test

cale

iologic Studies Depression Scale

r Hassles Scale

l

Agitation Inventory - observer-derived

f-derived score

COPE Care of Persons with Dementia in their EnvironmentsCOWA Controlled oral word associationCQLI Caregiver Quality of Life InstrumentCR Care recipientCSDD Cornell Scale for Depression in DementiaCSQ Caregiver sleep questionnaireCTIS Computer-Telephone Integration SystemDBS Disruptive behavior scaleDMSS Dementia Management Strategies ScaleDRS Depression Rating ScaleDSC Dementia Steering CommitteeECR Elderly Caregiver Family RelationshipEPC Evidence Based Practice CenterESP Evidence-based Synthesis ProgramFIM Functional Independence MeasureGDRS Geriatric Depression Rating ScaleGDS Global Deterioration ScaleGIPB Geriatric Indices of Positive BehaviorGPS Global Positioning SystemGQ-SRs Good quality systematic reviewsHBPC Home Based Primary CareHDLF Health and Daily Living FormHDRS Hamilton Depression Rating ScaleHSR&D Health Services Research and DevelopmentHTA Health Technology AssessmentIADL Instrumental Activities of Daily Living scaleICT Information and Communication TechnologyITT Intention-to-treatLSIZ Life Satisfaction IndexLSNI Lubben Social Network IndexLTC Long-term care
56

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

jective Checklist

er’s Disease Demonstration and 

m

ment Inventory

vior Problems Checklist

Workshop

Exam

Observation Scale for Older Subjects

oblem Behaviors

ulation

rvice

on Aging/National Institute of Nursing for Health and Clinical Excellenceof Neurological and Communicative 

e

nventory

ity

Resource and Services Multidimensional 

ment Questionnaire

ys of affect scale

s and Extended Care

f Caregiving scale

ustment to Relative’s Illness

sive Behavior in Demented Patients

tia Care

stionnaire-9 Item

ving

tates

cale

d life years

RAGE Rating Scale for Aggressive Behavior in the ElderlyRCT Randomized controlled trialREACH Resources for Enhancing Alzheimer’s Caregiver HealthRIL Record of Independent LivingRMBPC Revised Memory and Behavior Problem ChecklistRSCSE Revised Scale for Caregiving Self-EfficacySADS Social Avoidance and Distress ScaleSBP Stress-Busting ProgramSCB Screen for Caregiver BurdenSCN Suprachiasmatic nucleiSF-36 (PF, Short-form health survey (physical functioning andPRF) physical role functioning subscales)SIP (BCM, Sickness Impact Profile (mobility scale; home M, HM) management subscaleSPT Simulated presence therapySR Systematic ReviewSSCQ Short Sense of Competence QuestionnaireSTAI State Trait Anxiety InventorySTAXI State Trait Anger Expression InventoryT1 Timepoint 1T2 Timepoint 2TENS Transcutaneous electrical nerve stimulationTLC Telephone-Linked CareTx TreatmentUK United KingdomVA Veterans AffairsVAMC Veterans Affairs Medical CenterVAS Visual analog scaleVHA Veterans Health AdministrationVISN Veterans Integrated Service NetworkVSO Visit Satisfaction QuestionnaireZBI Zarit Burden Interview
57

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

VIEWER COMMENTS AND RESPONSES

Response

ethods for this review clearly described?

Noted.Noted.

ully addressed. An unfortunate feature of the study is that the 

ative. In spite of this, the findings are useful in determining 

ople with dementia.

Noted.

macological interventions classified as “psychotherapy” (e.g., 

herapy, simulation presence therapy, and many behavioral 

es) are not typically considered as psychotherapy. Furthermore, 

eferenced in the results and conclusion but is not listed as an 

thods section. It is also not clear what is meant by behavior 

Additional specification or definition would be helpful, as this is 

 technically involves a specific type of psychotherapy.

This section has been changed to clarify terminology and follow the outline of the report.

eview included studies on management of behavioral symptoms 

variety of settings, including all outpatient settings, home-based 

e settings may have affected the findings and contributed to 

ve results in some cases if data were analyzed in the aggregate. 

may work differently or require adaptation in different settings. 

iew and report results for different settings separately. This 

for guiding application of the results and future research 

There were insufficient numbers of behavior management studies to examine effects within subgroups by setting, provider type, and patient population, and therefore results were aggregated. The diversity of the settings examined across studies prohibited grouping based on this variable. Additionally, all behavior management technique studies had methodological limitations, and no subgroup of studies was exempt from these limitations.

our synthesis of the evidence? 

Noted.Noted.Noted.Noted.

do not see evidence of bias but am unclear as to whether there 

y studies that conducted on a particular topic between the time 

matic review and July 2009. Many of the systematic reviews in 

e published in 2008 and 2009 but there are also several that were 

 For those systematic reviews published prior to 2007, was a 

more recent articles?

The breadth of this report’s scope is enormous given the variety of interventions being considered. It would have not been feasible to systematically conduct updated searches for primary literature for each of the interventions under consideration. We did, however, consider newer primary studies identified through expert input and resources like the AoA compendium when applicable and we discuss them if they added to the body of literature already cited. 
58

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

Response

armacological interventions for behavioral symptoms of dementia that we have overlooked? 

on the following types of interventions that were to be included 

behavioral management techniques; cognitive rehabilitation; 

herapy; reality orientation)

gies

The initial review of psychotherapeutic techniques incorrectly ruled out behavior management techniques as being administered by the caregiver and therefore included in a separate ESP report. In light of the feedback, we reexamined the literature on behavior management techniques and include this as a section in the updated report.The report included smart home technologies such as tracking devices, motion detection devices, and home alarms within the section on wandering. No additional reviews meeting our quality criteria reviewed research on smart home technologies targeting symptoms other than wandering.

ventions that were to be focus of review were “psychotherapy 

gement techniques...”) They are notably absent in the 

his literature indicates that there are a number of well-done 

nstrated the utility of behavioral management approaches to 

ated behavioral problems. I’d like to bring one leading article 

don, R.G., McCurry, S.M., & Teri, L. (2007). Evidenced

eatments for disruptive behavior in individuals with dementia. 

, 22, 28-36. The authors utilize the American Psychological 

for identifying evidence based treatment to review studies in 

de (from the abstract): “Results of this review indicate that 

lving therapies that identify and modify antecedents and 

em behaviors and increase pleasant events and individualized 

 progressively lowered stress threshold models that include 

nvironmental modifications meet EBT criteria.” The specific 

fy as meeting EBT criteria are delineated in the article. 

The initial review of psychotherapeutic techniques incorrectly ruled out behavior management techniques as being administered by the caregiver and, therefore, was included in a separate ESP report. In light of the feedback, we re-examined the literature on behavior management techniques and include this as a section in the updated report. We have included the Logsdon et al. (2007) article in the updated report.

worth mention include:

ns, A.B.,& Burgio, L.D. (1999). Effective behavioral 

asing dementia-related challenging behavior in nursing homes. 

f Geriatric Psychiatry, 14, 213-232.

z, M. (2000). Psychosocial interventions for individuals with 

on of theory, therapy, and a clinical understanding of dementia. 

eview, 20, 755-782.

001). Nonpharmacological interventions for inappropriate 

 A review, summary, and critique. American Journal of Geriatric 

. 

We reviewed all of these articles, and none met our quality criteria for inclusion in the report. Additionally, similar articles which met our quality criteria are included in the report and adequately cover the topics in these suggested articles (Ayalon et al., 2006; Livingston et al., 2005; & Logsdon et al., 2007).
59

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

Response

view articles cited in your report, the authors draw favorable 

utility of behavioral interventions for dementia. Livingston 

tic review of psychological approaches to the management 

mptoms of dementia. American Journal of Psychiatry, 162, 

havior management therapies, specific types of caregiver and 

ducation, and possibly cognitive stimulation appear to have 

or the management of dementia-associated neuropsychiatric 

e abstract) 

Noted. See response to previous comments re: inclusion of behavior management techniques as a section in the updated report.

very carefully done. Noted. 

y, I suggest you also look at the following compendium from 

ng (AoA). This was also used by the Portland ESP group that 

n Interventions for Non-professional Caregivers of Individuals 

ging’s Alzheimer’s Disease Supportive Services Program. 

hy: Evidence-based interventions that target people with ADRD 

10. http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/

010.pdf 

We reviewed the AoA compendium for relevant, recent studies related to behavior management techniques and did not find any that met our criteria. Relevant studies included work by Linda Teri that was already included in the report, as well as other articles referencing behavior management techniques that were limited to assessing caregiver outcomes rather than patient outcomes.

ant research by Burgio and Cohen-Mansfield (e.g., Burgio 

nsfield et al., 2007), which provide further support for non

oaches to managing dementia-related behaviors. Were these 

ed in the reviewed research?

Based on this feedback, we reviewed both primary articles. The CohenMansfield article was included in the section on agitation as it was part of the Kong (2009) review that was cited in that section; we did not examine primary articles in this section of the report. Though the Burgio (2002) article was citedin the reviews included in the BMT section of our paper, it was not included as evidence in these reviews for the same reason that it is not applicable to this review: This research examines two BMT interventions with different staff training strategies. Because there is no control group receiving a nonBMT intervention, there is no way to examine the effects of BMT overall (only the relative efficacy of different types of BMT); therefore, any change in outcome could be due to maturation rather than intervention. Related work by Burgio was also included in the reviews cited in our report and, therefore, this research is represented in our overall reporting of results. Though these articles both provide some support for the effectiveness of certain behavior management techniques, unfortunately, neither one is methodologically rigorous enough to change our overall interpretation of findings.

ay be of interest. Wall M, Duffy A. The effects of music 

le with dementia Br J Nurs. 2010 Jan 28-Feb 10;19(2):108-13. 

This study was not included in the report because it was outside our search timeframe. In reviewing the findings, however, we noted that the authors of this paper came to the same conclusions as we did regarding the effectiveness of music therapy: Though initial research documents positive results in terms of reducing agitation, methodologically sound studies are needed to adequately support positive results.
60

ons for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

Response

Results

 page ix) – 

 on several groups of interventions that were to be included in 

, behavior management, cognitive rehabilitation, cognitive 

entation;

gies

y statement on comparison of non-pharm interventions with each 

acological approaches?

Noted. See response to previous comments re: inclusion of behavior management techniques as a section in the updated report. We added a summary statement on the lack of comparison information.See response to previous comment re: smart home technologies being covered in the section of the report on wandering.

e ix) –

 on several groups of interventions that were to be included in 

, behavior management, cognitive rehabilitation, cognitive 

entation;

gies

y statement on comparison of non-pharm interventions with each 

acological approaches?

Noted. See response to previous comments re: inclusion of behavior management techniques as a section in the updated report. We added a summary statement on the lack of comparison information.See response to previous comment re: smart home technologies being covered in the section of the report on wandering.

s (page 2) – Throughout the report

on several groups of interventions that were to be included in 

, behavior management, cognitive rehabilitation, cognitive 

entation;

gies

Noted. See response to previous comments re: inclusion of behavior management techniques as a section in the updated report.See response to previous comment re: smart home technologies being covered in the section of the report on wandering.

age 28, 34, elsewhere?) – 

er who has a focus on wandering.

Done.

 2 (page 33)

, consider adding a statement about the comparison of non

ith each other, and with pharmacological approaches. If there 

, you could have a statement to that effect as you do on page 31 

Agreed. This statement has been added.

mments/suggested edits are shown in Track Changes on the 

ostly punctuation/grammar changes for clarification).

All edits included in the document were addressed. Because they primarily consisted of word grammar edits and are not in need of additional discussion, they are not itemized here.

avioral interventions to one of the key areas addressed in this 

Noted. See response to previous comments re: inclusion of behavior management techniques as a section in the updated report.

tained additional articles from reference lists of pertinent 

 should be more fully explained below in “Study Selection and 

Manual searching for articles that were not identified through the systematic search of electronic databases is a standard, supplemental search method used in conducting systematic reviews. 
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Response

s that individuals with dementia experience.” Awkward?; 

nced by individuals with dementia?”

Agreed. This sentence has been changed.

of the systematic reviews captured in our search identified any 

t directly compared safety among different non-pharmacological 

een non-pharmacological and pharmacological treatments.”

This section of text refers to safety, while the previous text refers to effectiveness.

BEHAVIORAL MANAGEMENT TECHNIQUES DO YOU 

MODIFICATION ?: Behavior modification is the use of 

ted behavior change techniques to improve behavior, such 

al’s behaviors and reactions to stimuli through positive and 

t of adaptive behavior and/or the reduction of maladaptive 

xtinction, punishment and/or therapy.

Due to the broad range of interventions covered, as well as the need to group them into an accessible organizational framework, we chose to use the term “Behavior management techniques” to represent the variety of techniques which were investigated. We agree that many different terms are used in the field, though this choice of terminology is consistent with other articles (e.g., Logsdon et al., 2007, refer to “behavior management interventions and Livingston et al., 2005, refer to “behavioral management techniques”). 

organized the literature into the following categories.” Should 

rationale underpinning your categorization schema? For 

L of listed categories be considered “Behavioral Management?”

All categories focus on reducing behavioral symptoms of dementia; however, we organized the review in a manner such that similar types of interventions were grouped, consistent with existing literature (e.g., Livingston et al., 2005). We agree that other organizational frameworks could have been considered, though we believe that this is the most parsimonious manner in which to adequately capture all relevant techniques.

 the exception of one small trial (N=17) that showed a benefit on 

n?

We chose not to include citations because this text is in the summary of findings for this section. Citations are provided in the subsequent section that provides the results in greater detail.

review identified three additional studies that could not be 

analysis; of these, two studies found that SPT was effective in 

ehaviors, and the third found no overall benefit, and that the 

differ among individuals.”

discussed in this work should be cited.

Because our overview of non-pharmacological interventions summarizes the work done previously by other systematic reviews, we refer to the systematic reviews themselves rather than the individual studies these reviews included. BMT was an exception to this format because we focused on the individual studies that had been identified by previous systematic reviews. 

g the four week treatment period” May need hyphen. This change has been made.

 indeed! You may need to break this broad category into 

xample, functional behavior analysis, token economies and 

ral reinforcement strategies are clearly catagorizable as 

n;” other inclusions here a “stretch...”

We considered many different ways of organizing this category. The reviews and even the individual studies included such a variety of intervention components that separating “specific ingredients” into subgroups was not possible. As noted above, due to the broad range of interventions covered, as well as the need to group them into an accessible organizational framework, we chose to use the term “behavior management techniques” to represent the variety of techniques which were investigated. We agree that many different terms are used in the field, though this choice of terminology is consistent with other articles (e.g., Logsdon et al., 2007, refer to “behavior management interventions and Livingston et al., 2005, refer to “behavioral management techniques”). 
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e good quality systematic reviews, including a total of 31 studies, 

ness of behavior management techniques for the treatment of 

of dementia.” Cite!

We agree and have added the citations to these 3 systematic reviews.

more effective/useful if column added to list primary author and 

Due to space limitations, we chose not to include the primary author list and, rather, included this information as citations within the table.

S - need to define abbreviation. This change has been made.

t cognitively impaired elderly adults are at increased risk of 

aneously a potential rationale for and risk of exercise programs.” 

The previous sentence documents this same point and includes 2 relevant citations.

Note font variation in ref #4 This change has been made.

e thoughts about whether you can make any statement about 

ety of non-pharm versus pharm approaches, even though there 

mparisons. Otherwise, the serious risks of pharmacological 

.

We agree that, given the dearth of direct comparisons, statements implying a comparison of approaches are not warranted; therefore, we only included statements about the dearth of research rather than any statements about the relative efficacy and safety without adequate documentation of comparisons.

 text on behavioral management techniques (BMT) found on 

s pages vii, xi, 39, 43, 46, and 50: 

d information on the study setting? (Table 2 has a column for 

Due to the other information included in the table, there was no additional room for more study details, and we tried to include the most relevant information in the table.

sary of tests included in the “Outcomes” column, to spell out the 

Yes. This has been added.

roughout the document – be consistent in use of present or past 

dy results (e.g., page 23, line 5 has past tense, “...Gitlin...was 

e 22 has present tense, “Though they use a more conservative p 

This change has been made.

ype 1 error” This term has been defined.

 value” This term has been defined.

 setting of the Teri, Huda, et al. (2005) study was nursing home, 

n References section page 55, line 4 says assisted living staff. 

f the study. 

This correction has been made.

this is a comment for the report, but just to let you know 

h is currently pilot-testing an adaptation of the Teri STAR 

unity Living Centers.

Thank you for this information.
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his report examined a broader range of primary studies...” – 

lude the studies mentioned in the preceding bullets, or is this 

ome other studies? (Maybe I just didn’t follow correctly.)

This paragraph has been re-worded for clarity.

grade of B” We chose not to include additional information on this definition in text but 

provided additional contextual information in the report (i.e., describing the findings) so that readers could more easily interpret the grade-related findings. We have added a citation to the Oxford Centre for Evidence Based Medicine (http://www.cebm.net) for further information on their particular grading system. 

arts of the report:

r possible, be consistent in order of results for the types of 

me order in Executive Summary, Table of Contents, and in body 

We have examined the report for consistency in ordering of interventions and have made changes as needed to maintain consistency throughout.

raph, on TENS – Can you clarify the last sentence -- If no 

d in 3 RCTs, why say there is insufficient evidence? (e.g., poor 

hough there were 3 RCTs?)

In order to clarify the conclusions, we have stated the conclusions made directly by the authors of the Cochrane review on TENS.

ion 2 – If possible, use same order as in Key Question 1 

tarting on page iv (put Behavior management techniques 

mal-assisted therapy....)?

This change has been made.

x G, Reviewer comments – Just a reminder that these should be 

Noted.

placement of individuals with dementia into residential care.” This change has been made.ome based care and ambulatory care; and extended care....” 

home-based care, and use semi-colon after ambulatory care?]

This change has been made.

e 9 top – Why not cite the individual studies and give their 

ble), rather than the review references 10 and 11?

Because our overview of non-pharmacological interventions summarizes the work done previously by other systematic reviews, we refer to the systematic reviews themselves rather than the individual studies these reviews included. BMT was an exception to this format because we focused on the individual studies that had been identified by previous systematic reviews.

em behaviors.” [Add references] Given the broad scope of this report, whenever possible we summarized 

the findings of existing systematic reviews. Because in most cases we did not review the individual studies ourselves, we chose to refer only to the systematic review as the primary source.

me individuals.” This change has been made.

g persons with dementia.” This change has been made.

nd 8-11 – give references? Please see response to item “8a” above.
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Response

nce? Please see response to item “8a” above.

nce? Please see response to item “8a” above.

are.” This change has been made.

eference? Please see response to item “8a” above.

 and line 27 – give references? Please see response to item “8a” above.

 and line 29 – give references? Please see response to item “8a” above.

mma after “dementia” This change has been made.

mma after “massage” This change has been made.

ons with dementia in the...” This change has been made.

rved in individuals with dementia...” This change has been made.

 “...in persons with dementia...” This change has been made.

ne 3, line 8, line 11, line 14 – add references. Please see response to item “8a” above.ne 9, line 10 – add references. Please see response to item “8a” above.

ify, is it the British National Institute for Health and Clinical 

Yes. This change has been made.

or present tense (be consistent) This change has been made.

 row, column on Intervention - viewed (past tense) This change has been made.

ond row, column on Setting – What kind of “Veterans home” – 

The primary article describes the setting as a “20-bed special care Alzheimer’s unit in a midwestern Veteran’s home.” The article provided no further details. 

 Spell out “BMI” if first time used. This change has been made. Spell out “MSS” if first time used. This change has been made. Do you mean, “...on the behavioral symptoms of agitation in 

Yes. This has been edited for clarity.

no systematic reviews on inappropriate sexual behavior. Did 

al studies on this topic?

Given the scope of this report, we did not search for individual studies on inappropriate sexual behavior. However, we recognize that it is an important topic that may warrant a focused systematic review of primary studies. 

 sentence says the opposite of this sentence? (clarify?) This has been clarified. There were no head to head studies; only one review 

attempted to examine results across studies by comparing effect sizes.

Can you add a concluding sentence for this paragraph? This has been added.

 Add reference number closer to name HTA to make clear it is 

This change has been made.

The HTA report [add ref number here]...” This change has been made.
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Response

f first table on the page – “The symptoms, comparators, [add 

d settings are best dealt with using inclusion and exclusion 

n here]....”

This change has been made.

s review of non-pharmacological approaches to managing 

enging behaviors. This is an area of important focus for VHA, 

he lack of evidence for and increased death risk associated 

chotics with older patients. The manuscript is generally 

 are some comments to consider as the report is finalized, in 

nts provided above.

Thank you for this feedback.

elled This correction has been made.

nagement interventions is referenced, but is not defined as other 

This section has been updated to include a definition.

rs to “behavior management techniques” and at other times 

ent techniques”. This should be made consistent. 

This term is now consistently “behavior management techniques” throughout the report.

ferred to throughout the report, though it is not clear what this 

While behavior management techniques are referred to throughout the report, behavior therapy is referred to only in relation to the agitation findings. This is the term used in the review cited within the agitation section. Due to space limitations, none of the interventions in this section (social contact, environmental modification, caregiver training, and behavior therapy) were defined, under the assumption that readers could examine the cited systematic review if they want more specific information than this included in this report.

f the Logsdon, Teri, et al.(1997) study states “yet there was no 

f cognition”. Unless the reference to “cognition” is meant to 

 statement is unclear as one would not expect to see change in 

vior management intervention.

The wording of this summary has been changed to clarify the results.

s of studies across different settings (and patient populations 

rent levels of dementia and behavioral severity) may attenuate 

rhaps in studies examining behavior management interventions. 

 results/conclusions separately for different settings, to the extent 

We considered many different organizational strategies, and reviewed existing literature for models (e.g., Livingston et al., 2005). The reviews and even the individual studies on behavior management techniques included such a variety of intervention components that separating “specific ingredients” into subgroups was not possible.

ehavior management techniques are aggregated in the report. 

ts a very broad array of interventions, thus limiting its internal 

y contributing unclear or inconsistent findings. 

We agree that the broad range of interventions and intervention components limit our ability to draw conclusions from this body of literature. We did look at each study and individual interventions, but there was very limited data for any single intervention. Therefore, it’s difficult to conclude that there is a strong body of evidence for any single intervention. 
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Response

there is no evidence demonstrating an effect of various of 

mental modification, caregiver training, combination training, 

 the behavioral symptoms of dementia.” This is unclear, as 

script evidence in support of one or more of these types of 

ed. Furthermore, this section is labeled as addressing agitation, 

e relates more broadly to “behavioral symptoms of dementia”. 

clear whether some of Cohen-Mansfield’s seminal work in this 

This paragraph has been re-worded for clarity. Now the paragraph specifically refers to behavioral symptom of agitation. The review examined in this section (Kong, 2009) did include relevant Cohen-Mansfield work on this topic (1986, 2001); however, Cohen-Mansfield’s (2007) work was not included in the review because the review search dates only extended through 2004. Based on this reviewer feedback, we obtained this primary article and updated the report accordingly. Thank you for this suggestion.

he greatest evidence reported was for behavior management 

 seem that this should be reported earlier in the Discussion. 

The discussion section has been ordered to follow the presentation of interventions in the rest of the paper, per reviewer requests; however, much of the discussion is devoted to behavior management techniques as we agree that these intervention strategies included the greatest evidence.

ow” level (versus, for example “Medium”) of evidence assigned 

ment interventions seems inconsistent with the findings of the 

is area. While findings are not consistent across all studies, 

her research) has provided some moderate level of support for 

entions. Further, as noted above, this category aggregates a wide 

s of interventions that may contribute to inconsistent findings.

The rating of “low” rather than “medium” was used in reference to behavior management techniques because of the methodological concerns that occurred across studies. Inadequate blinding of raters, providers, and participants is a major threat to the internal validity of the existing studies, particularly as most outcomes were assessed by self-report or caregiver report; it is very likely that, following participation in what one knows to be the treatment condition, a participant or caregiver would (possibly inadvertently) provide a more positive rating on outcome measures simply due to being aware of participation. In addition to blinding concerns across all but one study, the reviewed studies also suffered from other threats to validity including using control groups that were non-intervention or waitlist controls, poorly defined/operationalized interventions, inadequately accounting for nesting, and inadequately adjusting for increased risk of a Type I error due to using multiple outcome measures. Though many of these studies reported positive results, the inconsistencies in results were noted both across studies and within studies. The inconsistent results included different results across timepoints as well as across measures assessing similar outcomes. We attempted to adequately describe the multiple positive findings reported by RCTs while also noting the methodological limitations across all studies. We agree that, overall, this area of research is promising; however, methodologically rigorous research conducted across research groups is needed to provide unequivocal support for the effectiveness of behavior management techniques. 

management techniques is a welcome addition to the 

any caveats raised in the report about the quality of studies 

havioral symptoms of dementia, behavioral management 

e some of the more promising interventions among them.

Noted. We agree and attempted to present the findings in such a way that this was presented in the BMT section and discussion.
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Response

armacological vs. pharmacological approaches regarding their 

uestion 2) and cost (Key Question 3).

conclusions when there are head-to-comparisons between 

and pharmacological studies. Might it be possible draw some 

e questions based on the broader aggregate of findings?

Because there was no research-based evidence on this topic, we chose not to include this information in the body of the report. This is because the strength of evidence is compromised when the effectiveness of two interventions is indirectly compared. However, we included this point in the discussion section of the report as we agree that this is an important consideration for future research directions.

 notes: “Psychotropic medications are commonly used to reduce 

erity of the behavioral symptoms of dementia. There is little 

at such interventions are effective, and their potential side effects 

hazardous. It has been reported that the use of atypical and 

medication is associated with the increased risk of death.” In 

be imprudent for the report to conclude that despite the mixed 

macological interventions, they should be first line of treatment 

ogical approaches? That is because non-pharmacological 

s. potentially serious side effects of medications) and some 

tive with certain behavioral symptoms or constellation of 

This is an important point to include in the discussion section, and we have included such a discussion in the report. We chose to include this in the discussion section rather than the body of the report because there is no research-based evidence to document on this topic.

t clear what the term “clustering” refers to. The term “nesting” has been added to this table to clarify the meaning of the 

column header.

verall, there is no evidence demonstrating an effect of social 

 modification, caregiver training, combination therapy, or 

e behavioral symptoms of dementia.” Since this section 

itation, shouldn’t this read “...on symptoms of agitation in 

This paragraph has been edited for clarity.

hat years were the primary studies searched? The search for primary studies for animal-assisted therapy was conducted 

from database inception through 12/9/2009, as noted in Appendix B.

d this section confusing. “We identified 22 good quality 

single nonpharmacological interventions plus 8 good quality 

9). The rest of this paragraph mentions 10 reports (line 10), 12 

orts( line 12), 3 reports (line 14), 5 reports (line 15) and 1 report 

ts add to 34 reports.

Yes, some of the reports reviewed multiple interventions and are therefore included in more than one subsection; therefore, reports used in subsections are not additive due to the fact that they are not mutually exclusive. The number of reports was inconsistent with other areas of the report, however, and this inconsistency has been corrected.
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Response

ment, the terms “behavioral symptoms”, “behavioral problems”, 

bances “seem to be used interchangeably. If these terms each 

ent, could definitions. For example: The three key questions 

vioral symptoms” but many of the discussions use “behavioral 

ioral disturbance.” The Background section (page 1,) uses both 

problems” and “behavioral symptoms”. If the terms all refer to 

it be helpful to use only one term?

This terminology has been made consistent throughout the report; now, behavioral symptoms is referred to throughout the document.

ulation is adults with mild, moderate, severe dementia.” Since 

 of dementia, did studies discriminate between types of 

this report define “dementia?” 

We proposed to use broad categories of dementia in our scope and objectives, in order to not limit the population of interest. Our search strategy in Appendix A shows the various terms we used to search for dementia in the literature. We relied on the definitions and diagnostic criteria used by the individual systematic reviews and the primary studies they included.

ories of drugs are mentioned with the exception of memantine 

cation listed by name. To be consistent, might want to say 

onist rather than memantine.

This change has been made.

at 28 systematic reviews were included—seems inconsistent 

n Executive Summary. 

This inconsistency has been corrected.

fusing—I am not following how the numbers add up Some of the reports reviewed multiple interventions and are therefore 

included in more than one subsection; therefore, reports used in subsections are not additive due to the fact that they are not mutually exclusive.

reminiscence therapy refers several times to “problem 

what these problem behaviors are that were assessed in the 

eminiscence. 

This terminology has been made consistent throughout the report; now, behavioral symptoms is referred to throughout this section and the entire document.

or Management Techniques (page 19-20) does not have any 

ous reviews and studies are mentioned. This might pose a 

anting to obtain additional information about these techniques

We agree and have cited the systematic reviews. 

ive/emotion-oriented interventions and sensory-stimulation 

htforward. The Behavior Management Techniques section is 

ation of behavior management techniques (page 19, lines 27-

meant by “functional analysis of specific behaviors”? What are 

What is meant by habit training—what habits? 

These terms have been clarified in the report.

nd 22 seem disconnected from the discussion on pages 23 and 

We chose to include the table in text to summarize the entire behavior management technique section.

age 24, describing specific study findings, do not correspond to 

studies are mentioned in Table 1. A reader, reading the bullet 

y want additional information about a particular study. The 

 the table to try and match the references. Would it be better to 

reflect the same order of the studies in the table. 

The table and bulleted list are in the same order.
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Response

ugh the three reviews cited in this report . . . “ Not clear which 

discussed here—there are more than three reviews discussed in 

This sentence has been clarified.

ble 1 and Table 2 are embedded in report but there are no 

ections on cognitive/emotion-oriented interventions, sensory

ns, wandering, or agitation.

These were the only two sections which included primary studies and therefore we included evidence tables for only these two sections in the report.

me inconsistency as to what the interventions are called 

—sometimes they are “therapies”, sometimes “treatments”, 

macological interventions”, sometimes “psychosocial therapies”, 

aches”. 

These terms are used interchangeably throughout the report; specifically, we tried to use terminology reflective of the terminology used in the various reviews we were citing and, therefore, we used all of these terms in the report.

good. Noted.

ons that masters level personnel are required for the emotion

The only other place in the report that level of education for the 

ioned is in Table 1. If level of education is relevant (and I think 

n should be mentioned in the text of the report when discussing 

oaches.

We have added additional information to other sections of the discussion; additionally, information on degree requirements is included in Table 3.

the conclusion, I might be interested in and want to read more 

vention that shows some promise. I think it would be helpful 

 when discussing these interventions. For instance on page 

helpful to provide the citation for those studies that “suggest 

ment techniques are effective strategies to reduce behavioral 

.”

We have included a reference to Table 1 in this section of the discussion.