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For clinicians  ·  For facilities  ·  For families  ·  For staff

Non-drug approaches you deliver

For facility staff

These are the first line, not the fallback. That is not a nicety — it is the order the guidelines set, and it exists because a behavior that resolves when someone is taken to the bathroom was never a psychiatric symptom.

The eight things

  1. An established daily routine, to provide structure and reduce agitation.
  2. Safe physical activity — a walk, 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.

Half of that is a list of unmet physical needs

Items 6, 7 and 8 are not behavior management. They are checking whether the person is uncomfortable. Someone who cannot say they need the bathroom will show you instead, and what they show you looks like agitation.

That is why the order in which things get checked is the difference between a resolved afternoon and a new prescription.

What the guidelines actually require

This is not a preference. The American Psychiatric Association’s practice guideline 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.

So a record of what you tried and what happened is not paperwork. It is the thing that makes the next clinical decision legitimate.

What the evidence says about which ones help

A network meta-analysis of 163 randomized studies covering 23,143 people with dementia compared approaches to aggression and agitation. Against usual care, three came out ahead: music combined with massage and touch therapy, massage and touch therapy on its own, and multidisciplinary care. Recreation therapy was statistically but not clinically better. The authors concluded that non-pharmacologic interventions “seemed to be more efficacious than pharmacologic interventions.”

Two honest qualifications. That review did not evaluate harms or costs, and 46% of its studies were at high risk of bias from missing outcome data.

Music, specifically — the honest version

Music matched to someone’s own history reliably changes the next twenty minutes for a lot of people, and twenty minutes is often what is actually needed. That is worth a great deal and it is not a treatment for dementia.

The 2025 Cochrane review of music-based therapeutic interventions — 30 studies, 1,720 participants, mostly people living in care homes — found they probably improve depressive symptoms slightly and may improve overall behavioral problems, but probably do not reduce agitation or aggression. That null result has been stable across three successive versions of the review. Music combined with massage and touch is a different intervention from music alone, and the evidence treats them differently.

Exercise — and the thing about exercise

In the 2025 Cochrane review of falls prevention in care facilities — 104 randomized trials, 68,964 participants — active exercise probably reduces the rate of falls (rate ratio 0.68) and the risk of falling (relative risk 0.86), and may reduce the risk of falling in residents with cognitive impairment specifically (relative risk 0.72).

And the finding that should shape how a program is run: after the intervention period, if exercise is not sustained, there is no effect on the rate of falls — rate ratio 1.02, and that is rated high-certainty evidence. Movement is a standing arrangement, not a course that finishes.

Why these fail in buildings that intend them

  1. They take time. An approach requiring four unhurried minutes does not exist where nobody has four minutes. This is a staffing fact, not a willingness fact.
  2. They are person-specific, so they only work if the plan is known on every shift. The care-plan item that fails most often is that everybody working with the resident knows it.
  3. They are not documented when they work. See below.

Write down what worked

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 a building is a record of its failures, and every review that reads that record concludes that nothing works.

“Settles if taken to the bathroom before 3pm.” “Calms down if given the towels to fold.” “Do not approach from behind.” Those sentences are worth more than most of what is in a care plan, and the reason they are missing is that nothing happened when they worked.

Back to the staff track.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

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. Watt JA, Goodarzi Z, Veroniki AA, et al. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Annals of Internal Medicine. 2019;171(9):633–642. PMID 31610547 · DOI 10.7326/M19-0993.
  3. van der Steen JT, van der Wouden JC, Methley AM, Smaling HJA, Vink AC, Bruinsma MS. Music-based therapeutic interventions for people with dementia. Cochrane Database of Systematic Reviews. 2025;3(3):CD003477. PMID 40049590 · DOI 10.1002/14651858.CD003477.pub5.
  4. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.
  5. Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs for people with dementia. Cochrane Database of Systematic Reviews. 2015;2015(4):CD006489. PMID 25874613 · DOI 10.1002/14651858.CD006489.pub4.
  6. Kales HC, Gitlin LN, Lyketsos CG; Detroit Expert Panel. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society. 2014;62(4):762–769. PMID 24635665 · DOI 10.1111/jgs.12730.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

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.