Several theoretical frameworks describe the manifestations of the behavioural, affective, cognitive and psychotic impairments associated with dementia from an environmental and psychosocial perspective. Three such theories that explain behaviour problems are the behavioural model, the environmental vulnerability model and the unmet needs model. Some of the theories that explain affect include the learned helplessness model and the reduced reinforcement model. There are also various theories relating pain and loneliness to affect. Each theoretical framework has different implications for intervention.

Behaviour

The behavioural model states that a problem behaviour is controlled by its antecedents and consequences. Antecedents include triggers that initiate the behaviour, such as the view of the exit door elic-iting an attempt to exit the institution; consequences refer to the reaction to the behaviour, such as when screaming is followed by attention from staff members, a response that reinforces the scream-ing behaviour. Alternatively, the environmental vulnerability model asserts that dementia results in an increased vulnerability to the envi-ronment, which leads to a lower threshold at which stimuli affect behaviour. A stimulus that may elicit an appropriate response in a person without cognitive impairment, such as a movie or magazine, may overwhelm a person with cognitive impairment and therefore generate an inappropriate behaviour. This model is based on the concepts of person–environment congruence¹ and the environment-behavioural model, which suggest that, for optimal functioning, a match is needed between the person’s needs and abilities and the demands of the environment as they relate to those needs and abili-ties. A related concept is that dementia results in a progressively low-ered stress threshold². Accordingly, persons with dementia progres-sively lose their coping abilities, and therefore perceive their envi-ronment as increasingly stressful. Since their threshold for tolerating this stress is also decreasing, anxiety and inappropriate behaviour can result as environmental stimuli exceed the person’s stress threshold.

According to the unmet needs model, a person with dementia has difficulty meeting his/her needs because of a decreased ability to communicate needs and provide for oneself. The loss in the ability to communicate and perform tasks. The combination of the loss of ability to communicate and perform tasks, inability to effectively uti-lize the environment, and deficiencies in individualizing care results in unmet needs^3,4. Problem behaviours emerge as an attempt to meet or to communicate those needs.

The different models are not mutually exclusive and may be complementary. An environmental vulnerability may make the per-son who suffers from dementia more susceptible to environmental antecedents and consequences. The environmental vulnerability may also produce an unmet need when normal levels of stimulation are perceived as over-stimulation. Furthermore, different models may account for different behaviours in different people.

Affect

Depressed affect has been conceptualized as resulting from lack of control and a sense of helplessness, from insufficient level of control over one’s environment⁵, or from an insufficient level of reinforcing activities, i.e. pleasurable experiences⁶. Depressed affect has also been linked to loneliness⁷ and to physical pain.

Delusions/Hallucinations

Delusions can represent a misinterpretation of reality, which may stem from actual environmental changes for which the person is not adequately prepared. This may be the case when an older person becomes frightened by a caregiver who comes to get her dressed, and whom the older person may perceive as a total stranger. Hal-lucinations have been associated with visual impairments, and may therefore represent a natural reaction to sensory deprivation⁸.

The following describes non-pharmacological interventions used for alleviating behavioural, affective, cognitive and psychotic symptoms of dementia.

Behavioural

Interventions for behavioural problems that are based on the unmet needs model most often focus on three types of unmet needs: need for social support and contact, need for stimulation and activities, and need for relief from discomfort. At the most basic level, providing social support and contact involves talking to persons with dementia, even if the caregiver conducts the majority of the conversation. One-on-one interaction is a potent intervention that can be performed by relatives, paid caregivers or volunteers. Alternatively, simulated social interventions can be useful when live social contact is not available; such interventions include videotapes of family members⁹, simulated presence therapy¹⁰, in which an audiotape of a family member’s side of a telephone conversation is played repeatedly to the person with dementia, or commercially produced interaction videos for persons with dementia, in which viewers are invited to sing along to familiar music or to remember past events. Training staff members to view all interactions with those in their care (such as during ADL) as opportunities for social contact is also an opportunity to provide social support.

Pet therapy is another option¹¹, which may include visits with dogs, cats or fish, or simulated pet therapy using plush stuffed animals or robotic pets¹². In addition to interaction with the animal, pet therapy provides a topic for interaction with other people. Dolls have also been used to simulate companions/babies, and massage may be an effective mechanism for social contact with non-verbal persons with advanced dementia.

In order to address the need for activity or stimulation, many differ-ent types of activities or stimuli have been used. Stimulation includes music, aromatherapy, touch therapy, ‘Snoezelen’ programmes, mas-sages and white noise. Structured activities, such as manipulation of objects, sorting, cooking, sewing and sensory interventions, may be helpful. Montessori-based activities are a set of activities based on Maria Montessori’s principles¹³, such as task breakdown, imme-diate feedback, and use of everyday, real-world materials. Other options for activities include exercise, art therapy, including drawing and painting, where participants can express themselves by choosing colours and themes, and adaptations of ADL, like setting the table or cooking.

Activities can include cognitive tasks that can be done individ-ually or within a group. Group examples include ‘Question Asking Readings’, in which a group reads a script accompanied by questions typed on cards that encourage participants to discuss related topics. Another group memory task is memory bingo, a game in which par-ticipants match beginnings and endings of popular sayings, which can also stimulate group discussion¹⁴. Individual cognitive tasks involve sorting cards or objects by category.

An alternative to addressing the need for stimulation by providing stimuli is to accommodate the behaviour that provides activity and stimulation. For example, interventions for accommodating pacing or wandering behaviour include outdoor walks¹⁵ and the use of wan-dering areas¹⁶. Inappropriate handling or the constant manipulation of objects can be accommodated by providing appropriate materials, such as books and pamphlets for handling, or activity aprons (aprons that have buttons, zippers and other articles sewn on) as appropriate and safe items for persons to handle. Similarly, rocking chairs and gliding swings have been used to accommodate restless behaviour and provide more acceptable stimulation.

Regarding relief of discomfort, interventions such as pain manage-ment, light therapy to improve sleep, and reduction of discomfort by improved seating or positioning and removal of physical restraints have all been related to improvement in behaviour. Changes in the methods and environment of providing ADL have also been associ-ated with reduction in inappropriate behaviours. For example, tape recordings and pictures of birds, flowing water and small animals in baths as well as offering food during bathing have been associated with a decrease of agitated behaviours during bathing. Person-centred showering and towel baths resulted in decreased agitation in com-parison with usual bathing routines¹⁷.

In order to provide for the unmet needs of the person with demen-tia, caregivers need to understand the needs and how to address them. Staff training is a category of non-pharmacological interven-tions, which includes training in skills such as communication and providing assistance in ADL, or in techniques to handle inappropriate behaviours. Many such programmes focus on improved understand-ing of the older person and the impact of dementia. Person-centred care and the use of dementia-care mapping are care principles that have been associated with decreased levels of behaviour problems¹⁸. Changing caregiver behaviour through training is, however, a com-plex and difficult challenge, and often requires ongoing instruction, modeling, monitoring, feedback and support of the caregiver. There-fore, in institutional settings, staff training is closely tied to manage-ment.

The most common intervention based on the behavioural theoreti-cal framework is differential reinforcement, which changes the con-tingencies that are supposed to maintain or reinforce the behaviour. This consists of positive reinforcement contingent on non-agitated behaviour, such as moving the person to a quiet area when agitated for time out, or restriction, where the person is denied goods (e.g. cigarettes), activities or access to a location or another person when agitated. In contrast, reinforcement is provided when not agitated.

The interventions based on the environmental vulnerability theo-retical framework include reduced stimulation units, which aim to eliminate the stimuli that, according to the theory, activate the low stress threshold and result in the problem behaviours. These units have been modified to appear less obstructive to those with demen-tia. They typically have small group sizes at tables for eating and small groups for activities, neutral colours on pictures and walls, no televisions, radios or telephones (except for emergencies), an educa-tional programme for staff and visitors concerning the use of touch, eye contact and slow, soft speech, use of quiet voices by staff at all times, and a consistent daily routine¹⁹.

Affect