Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

Investigators:

Principal Investigator:

Maya E. O’Neil, PhD

Co-Investigators:

Michele Freeman, MPH

Vivian Christensen, PhD

Robin Telerant, MD

Ashlee Addleman, MPH

Devan Kansagara, MD, MCR

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, MD, MCR, Director

A Systematic Evidence Review

of Non-pharmacological 

Interventions for Behavioral 

Symptoms of Dementia

March 2011
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Non-pharmacological Interventions

for Behavioral Symptoms of Dementia Evidence-based Synthesis Program

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the Portland VA Medical Center, Portland, OR funded 

by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development. The findings 

and conclusions in this document are those of the author(s) who are responsible for 

its contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement 

(e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material 

presented in the report.

PREFACE

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA.

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes and to 

support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: O’Neil M, Freeman M, Christensen V, Telerant A, Addleman A, and 

Kansagara D. Non-pharmacological Interventions for Behavioral Symptoms of Dementia: A 

Systematic Review of the Evidence. VA-ESP Project #05-225; 2011
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Non-pharmacological Interventions

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EXECUTIVE SUMMARY

BACKGROUND

In 2004, the Office of the Assistant Deputy Under Secretary for Health for Policy and Planning 

estimated that the total number of Veterans with dementia would be as high as 563,758 in FY 

2010.1 The VHA Office of Geriatrics and Extended Care (OGEC) in Patient Care Services 

has primary responsibility for coordination and direction of VHA dementia initiatives. OGEC 

convened an interdisciplinary Dementia Steering Committee (DSC) in December 2006, with 

the goal of making recommendations on comprehensive, coordinated care for Veterans with 

dementia.

The DSC requested VA HSR&D’s Evidence-based Synthesis Program (ESP) to review evidence 

on selected topics, in order to assist with DSC planning efforts. This evidence review addresses 

the following questions:

Key Question #1. How do non-pharmacological treatments of behavioral symptoms compare in 

effectiveness with each other, with pharmacological approaches, and with no treatment?

Key Question #2. How do non-pharmacological treatments of behavioral symptoms compare in 

safety with each other, with pharmacological approaches, and with no treatment?

Key Question #3. How do non-pharmacological treatments of behavioral symptoms compare in 

cost with each other, with pharmacological approaches, and with no treatment?

METHODS

We conducted searches for systematic reviews of non-pharmacological interventions for 

dementia in MEDLINE (PubMed), using the following search terms: (“dementia”[MeSH Terms] 

OR “dementia”[All Fields]) AND systematic[sb]. We also searched in the Cochrane Database 

of Systematic Reviews and the Cochrane Database of Reviews of Effects (OVID) from database 

inception through July 2009, using the term dementia.mp. We obtained additional articles 

from reference lists of pertinent studies. We conducted a separate search for primary studies 

of animal-assisted therapies because there were no existing systematic reviews on this topic. 

Additional primary studies were suggested for inclusion by reviewers based on recency and 

relevance to the field. We summarized the findings of good quality systematic reviews of the 

primary literature on the various non-pharmacological interventions. 

RESULTS

We identified 21 good quality systematic reviews that each examined a single nonpharmacological intervention, and seven good quality systematic reviews that reviewed a variety 

of interventions. Cognitive/emotion-oriented interventions were reviewed in 10 reports, sensory 

stimulation interventions in 12 reports, and behavior management techniques in 3 reports. We 

also added two primary studies related to behavior management techniques identified by our 

expert panel as neither of these more recent primary articles were included in previous systematic 

reviews. Three reports reviewed exercise. The search for primary studies of animal-assisted 
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Non-pharmacological Interventions

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therapies yielded nine prospective studies. Five reports reviewed a variety of interventions for 

wandering, and one report reviewed various interventions for agitation. Additionally, we added 

one primary study related to agitation identified by our expert panel as this recent study was 

not included in the previous systematic reviews. The findings for specific intervention types are 

summarized below.

Summary of Findings 

Key Question #1. How do non-pharmacological treatments of behavioral symptoms compare in 

effectiveness with each other, with pharmacological approaches, and with no treatment?

Cognitive/Emotion-oriented Interventions

Reminiscence Therapy: Reminiscence therapy involves the discussion of past activities, 

events, and experiences with another person or a group of people. Two previous systematic 

reviews identified seven small randomized control trials (RCTs) of reminiscence therapy. This 

limited body of evidence does not support the use of reminiscence therapy for the treatment of 

behavioral symptoms of dementia.

Simulated Presence Therapy (SPT): SPT involves the use of audiotapes made by family 

members containing a scripted conversation about cherished memories about the patient’s life. 

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.

Validation Therapy: Validation therapy is intended to give the individual an opportunity 

to resolve unfinished conflicts by encouraging and validating expressions of feeling. Four 

systematic reviews examined the effects of validation therapy in three RCTs as well as 

other study designs, and found mixed effects. Overall, there is insufficient evidence to draw 

conclusions about the efficacy of validation therapy for behavioral symptoms, depression, and 

emotional state associated with dementia.

Sensory Stimulation Interventions

Acupuncture: Acupuncture is an ancient Chinese treatment that has been used for over 3,000 

years. One systematic review found no rigorously conducted RCTs. There is no good quality 

evidence indicating benefit or harm of acupuncture for the treatment of behavioral symptoms for 

dementia.

Aromatherapy: 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. Overall, there 

is insufficient evidence that aromatherapy may be an effective treatment for agitation and other 

behavioral symptoms. 

Light Therapy: Light stimulation aims to improve the circadian disturbances in the sleep-wake 

cycles experienced by individuals with dementia. Two systematic reviews identified six studies, 

including two RCTs. Although some studies found beneficial effects of bright light therapy on 

agitation and nocturnal restlessness, studies were generally limited by small sample size and poor 

quality. The limited body of evidence is insufficient to draw definitive conclusions about the 

effects of bright light therapy in managing sleep, behavior, or mood disturbances associated with 

dementia.
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Non-pharmacological Interventions

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Massage and Touch: Massage and touch therapies aim to reduce depression, anxiety, and other 

behavioral symptoms of dementia. A systematic review identified two small RCTs that reported 

increased calorie and protein intake in a study that compared touch combined with verbal 

encouragement during meals to verbal encouragement alone, and reduced agitation in a study 

that compared hand massage with calming music and with no treatment. This limited body of 

evidence suggests that, compared with no treatment, hand massage and touch therapy may have 

beneficial effects.

Music Therapy: 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. 

We identified four systematic reviews that examined a variety of study designs. Three RCTs 

reported reduced aggression, agitation, and wandering while listening to music; and other studies 

found similar reductions in behavioral symptoms, although there was no evidence of long-term 

effects. All studies were limited by methodological issues. Overall, well-conducted studies are 

lacking, but music interventions have potential for reducing agitation in patients with dementia in 

the short term.

Snoezelen Multisensory Stimulation Therapy: Multisensory stimulation (MSS), otherwise 

known as Snoezelen therapy, combines the therapeutic use of light, tactile surfaces, music, and 

aroma. MSS is based on the premise that neuropsychiatric symptoms may result from periods of 

sensory deprivation. There were six RCTs identified among four systematic reviews. Although 

the evidence did not consistently demonstrate a durable effect of MSS therapy on behavioral 

symptoms, preliminary findings of short-term benefits and the reported pleasantness of the 

treatment suggest that future research is warranted.

Transcutaneous Electrical Nerve Stimulation (TENS): TENS is a non-invasive 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. A 

systematic review combined data from three RCTs in individuals with dementia and found 

no significant effects on sleep disturbances or behavioral symptoms, evaluated immediately 

after treatment or at six-week follow-up. Although some short-lived improvements in 

neuropsychological symptoms of dementia have been observed with TENS, definite conclusions 

on the possible benefits of this intervention cannot be made.

Behavior Management Techniques

Behavior management techniques 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. Findings from three systematic 

reviews including seven RCTs and two additional more recent trials provide some support 

for behavior management techniques as effective interventions for behavioral symptoms of 

dementia. However, mixed study results, the variety of specific interventions across studies, and 

methodological concerns in many studies suggest that additional research in this area replicating 

results is warranted.
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Other Psychosocial Interventions

Animal-assisted Therapy: There were no RCTs evaluating the effectiveness or harm of pet 

therapy. Nine non-randomized studies demonstrated decreases in agitated and disrupted 

behaviors, increases in social and verbal interactions, decreases in passivity, and increases in 

nutritional intake. The findings suggest that pet therapy has potential for benefit, but more 

rigorous studies are needed to establish benefit, harms, and feasibility for implementation in VA 

settings.

Exercise: Three systematic reviews of 59 studies showed inconsistent effects of exercise 

interventions on behavioral symptoms and functional status. Variations in intensity of exercise 

intervention, severity of dementia at baseline, and outcome measures make it difficult to draw a 

firm conclusion. Many of the included studies were small and did not use rigorous methodology. 

The most consistent evidence showed that exercise did increase sleep duration and decrease 

nighttime awakenings. While the impact of improved sleep on distal health outcomes remains 

uncertain, there may be an additional benefit to caregivers who are disproportionally affected by 

dysfunctional sleep.

Various Interventions Targeting a Specific Behavioral Symptom

Wandering: A variety of interventions for wandering were examined in four systematic reviews. 

There were no RCTs on the effects of subjective visual barriers, such as mirrors, floor grids, 

camouflage of doors or doorknobs, and concealment of view through door windows. Two RCTs 

determined that exercise and walking therapies had no impact on wandering. No evidence is 

available on the effects of wander gardens. Tracking devices, motion detection devices, and 

home alarms were generally effective in detecting wandering and locating lost patients in nonrandomized studies. Evidence about the effects of sensory stimulation therapies, such as MSS, 

aromatherapy, and music on wandering, is scant and inconclusive.

Agitation: A systematic review of agitation identified 14 RCTs of a variety of interventions. 

Three studies of sensory interventions (aromatherapy, thermal bath, calming music, and hand 

massage) showed a statistically significant decrease in agitation when combined in meta-analysis, 

but there was substantial variability in the type of intervention, duration of exposure, and 

outcomes measured. Other interventions including social contact, environmental modification, 

caregiver training, and behavior therapy showed no effects on agitation. One recently conducted 

primary study suggested to us by reviewers provided preliminary support for the effectiveness of 

systematic individualized intervention in decreasing agitation, though a lack of assessor blinding 

to condition limits the validity of these findings.

Inappropriate Sexual Behavior: There were no systematic reviews that examined the topic of 

inappropriate sexual behavior among individuals with dementia. Currently, the effectiveness of 

non-pharmacological treatments for inappropriate sexual behavior is unknown.

Comparative effectiveness among non-pharmacological interventions and between 

pharmacological and non-pharmacological approaches

None of the systematic reviews captured in our search identified any head-to-head trials that 

directly compared effectiveness among different non-pharmacological interventions, or between 

non-pharmacological and pharmacological treatments.
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Non-pharmacological Interventions

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Key Question #2. How do non-pharmacological treatments of behavioral symptoms compare in 

safety with each other, with pharmacological approaches, and with no treatment?

Cognitive/Emotion-oriented Interventions: One study found that simulated presence therapy 

increased agitation and disruptive behaviors in some patients. Reality orientation has been 

observed by caregivers to increase distress, fear, and agitation in individuals with later stages of 

dementia.

Sensory Stimulation Interventions: For some individuals, the increased stimulation from 

sensory stimulation therapies such as music therapy and massage/touch therapy may cause 

increased agitation and aggression. Consideration of the individual preferences in the use of 

these treatments should be emphasized.

Behavior Management Techniques: None of the systematic reviews nor the primary studies 

reviewed documented any patient harm or safety concerns resulting from the use of behavior 

management techniques.

Animal-assisted Therapy: The American Veterinary Medical Association guidelines describe 

potential physical and emotional harms associated with animal-assisted therapy, but the actual 

incidence of harms has not been well-studied. Theoretical harms include human injury, zoonotic 

disease, allergic reactions, and the risk of grief reaction if an animal dies.

Exercise: Potential harms of exercise programs include the increased risk of falls or physical 

injuries, but risks associated with exercise have not been well studied.

Comparative Safety among Non-pharmacological Interventions and between 

Pharmacological and Non-pharmacological Approaches

None of the systematic reviews captured in our search identified any head-to-head trials that 

directly compared safety among different non-pharmacological interventions, or between nonpharmacological and pharmacological treatments.

Key Question #3: How do non-pharmacological treatments of behavioral symptoms compare in 

cost with each other, with pharmacological approaches, and with no treatment?

None of the systematic reviews or primary articles we retrieved identified direct evidence on the 

cost-effectiveness of specific interventions. The costs associated with the use of GPS tracking 

devices and other monitoring systems are high, but the potential increases in patient safety and 

caregiver peace of mind associated with the use of these devices are notable. The training and 

veterinary care required for preparing and maintaining a live animal for animal-assisted therapy 

are costly. Some forms of animal-assisted therapy such as the placement of aquariums in dining 

areas may be less expensive than more individualized approaches. Behavior management 

techniques can include a variety of individualized interventions, and therefore expense for 

these techniques can vary greatly across individuals and settings. Further studies are needed 

to determine the cost-benefits, harms, and feasibility of these and other non-pharmacological 

interventions.