Non-pharmacological management of behavioural disturbances in dementia

Rationale and evidence. Non-pharmacological measures are first-line for all behavioural disturbance in dementia. A meta-analysis of 23 randomised trials in nearly 3300 community-dwelling patient–caregiver dyads confirmed that caregiver-directed interventions significantly reduce behavioural symptoms with an effect size of 0.34 — greater than that of antipsychotics for behavioural symptoms and of cholinesterase inhibitors for memory. Efficacy is best in mild and moderate stages, when cognition and communication are better preserved.

The DICE framework. Describe the behaviour, its context and its triggers with the caregiver; Investigate modifiable causes across patient, caregiver and environmental domains; Create a collaborative plan; Evaluate whether the target symptom improved, caregiver distress fell and no unintended effects occurred. DICE was designed for any health professional working within a team.

The five caregiver-training strategies with the strongest evidence base. Train caregivers to (i) use problem-solving skills to manage NPS; (ii) increase activity for the person with dementia; (iii) enhance communication within the dyad; (iv) reduce environmental complexity; and (v) simplify tasks for the person with dementia — supplemented by establishing structured routines and ensuring safety.

Interventions targeting the person with dementia. Music therapy, aromatherapy, exercise, tailored activity programmes, reminiscence and multisensory stimulation. Individual approaches work best embedded within tailored-activity programmes rather than delivered alone. Bright light therapy with good sleep hygiene is first-line for circadian rhythm disorder, for which there is no evidence for drug treatment.

Interventions targeting professional caregivers. In nursing homes, training and supervising paid caregivers in communication or person-centred care skills is effective for symptomatic and severe agitation, immediately and up to six months afterward. A systematic review and meta-analysis of 11 randomised trials showed psychosocial interventions in nursing homes reduced psychotropic drug prescribing, using three intervention classes — staff training on psychotropic prescribing and NPS management, consultation with external experts for complex NPS, and person-centred psychosocial interventions.

Interventions targeting the environment. Address over- or under-stimulation, safety problems, lack of activity and structure, and absence of established routine; add architectural modification improving secure access to the outdoors and helping navigation of the home or institution. Because strategies are used in combination, no single approach can be identified as preferred — a combination of environmental adjustments yields the behavioural change, and individual environmental studies remain too small and disparate for firm conclusions.

International Delphi expert consensus now formally places caregiver training, environmental adaptation, person-centred care and tailored activities ahead of any pharmacological approach for overall NPS and agitation, and identifies DICE and music therapy as the two most promising non-pharmacological approaches. This is reinforced by person-centred care packages such as WHELD and by Cochrane reviews of music-based interventions (2022–2025) showing consistent modest benefit on agitation and depressive symptoms with no drug-related harm — while digital and telehealth delivery of caregiver skills training (web-based psychoeducation, telecoaching, multicomponent platforms) has been shown feasible and effective, greatly widening access in resource-limited settings including India.