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Advocating for non-pharmacological interventions

A — the fifth step

Non-pharmacological approaches are the standing first line, not the fallback. The order is the argument: they sit after assessment and before every medication item, because a behavior that resolves when someone is taken to the bathroom was never a psychiatric symptom.

The eight things to look for

  1. Established daily routine, to provide structure and reduce agitation.
  2. Opportunity for safe physical activity — walks, simple exercise, somewhere to go.
  3. Meaningful activity: hobbies, music, sensory stimulation, matched to what the person can still do.
  4. A calm environment — reduced noise, appropriate light, familiar objects.
  5. Distraction or redirection when agitation arises, rather than confrontation.
  6. Frequent hydration, nutrition and bathroom breaks, to remove discomfort as a cause.
  7. Access to personal items that provide comfort.
  8. Seating that supports safe mobility and comfort.

Why “bathroom breaks” is on a behavior list

Because a person who cannot say they need the bathroom will show you instead, and what they show you looks like agitation. Roughly half of that list is really a list of unmet physical needs wearing a psychiatric costume. The order in which they are checked is the difference between a resolved afternoon and a new prescription.

What the guidelines actually require

This is not a soft preference. The American Psychiatric Association’s practice guideline on antipsychotics for agitation or psychosis in dementia states that the clinical response to non-pharmacological interventions should be reviewed prior to non-emergency use of an antipsychotic, and that antipsychotics should be used outside imminent-danger situations only when symptoms are severe, dangerous, or causing significant distress. More on antipsychotics in dementia.

What makes them fail in practice

  • They take staff time, which is why adequate ratio is a checklist item and not an aspiration. An approach that requires four unhurried minutes does not exist in a building where nobody has four minutes.
  • They are person-specific, so they only work if the plan is known to everyone on every shift — which is exactly the item most often missing.
  • They are not documented when they work. A redirection that settled someone in four minutes leaves no record. The intervention that succeeded is invisible and the one that failed is in the incident log, so the written history of the building is a record of its failures only.

The honest limit

None of these is a treatment for dementia and none of them stops its progression. What they change is the next twenty minutes, the number of times a day a person is distressed, and whether the answer to distress is a tablet. That is a smaller claim than the field sometimes makes and it is worth a great deal.

The randomized evidence on antipsychotics contains a finding that bears directly on this. A 2021 Cochrane review of 24 trials and 6,090 participants noted that the apparent effectiveness of these drugs in daily practice “may be explained by a favourable natural course of the symptoms, as observed in the placebo groups.” Much of what looks like a drug working is agitation resolving the way agitation tends to resolve — which is also why the non-drug approach so often gets no credit.

Common questions

Do non-drug approaches work as well as medication?

For agitation in dementia, the drugs themselves have a modest record: a Cochrane review of 24 randomized trials found atypical antipsychotics probably reduce agitation slightly and probably have a negligible effect on psychosis, against a clear increase in somnolence, extrapyramidal symptoms and serious adverse events. That is the comparison worth making. Antipsychotics in dementia.

What should happen before an antipsychotic is started?

The response to non-pharmacological approaches should be reviewed first, according to the American Psychiatric Association guideline, and non-emergency use should be reserved for symptoms that are severe, dangerous, or significantly distressing. The same guideline sets a four-week efficacy checkpoint and a taper attempt within four months for those who respond. The evidence on antipsychotics in dementia.

DWARAA is six steps. Back to the framework overview.

References

  1. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry. 2016;173(5):543–546. PMID 27133416 · DOI 10.1176/appi.ajp.2015.173501.
  2. Yohanna D, Cifu AS. Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. JAMA. 2017;318(11):1057–1058. PMID 28975291 · DOI 10.1001/jama.2017.11112.
  3. Mühlbauer V, Möhler R, Dichter MN, Zuidema SU, Köpke S, Luijendijk HJ. Antipsychotics for agitation and psychosis in people with Alzheimer’s disease and vascular dementia. Cochrane Database of Systematic Reviews. 2021;12(12):CD013304. PMID 34918337 · DOI 10.1002/14651858.CD013304.pub2.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.