Neuropsychiatric symptoms of dementia (NPSD) are prevalent issues affecting up to 45% of dementia patients.¹ NPSD can cause stress to caregivers, reducing patients’ quality of care and life, accelerating declines in physical and cognitive functions, and increasing the risks of physical or chemical restraints with negative consequences.¹ The high rate of access to open sources on managing behavior symptoms and medications for dementia indicates the need for detailed discussion and implementation of interventions.¹ In the 75^th AAN 2023 Annual Meeting, Dr. Julio C. Rojas discussed the importance of non-pharmacological management for dementia care and the structured ecosystem approach to develop strategies for better NPSD management.¹  

Patients, caregivers, and environmental factors contribute to the development of NPSD.¹ Regarding the biological factors, dementia patients experience varying degrees of neurodegeneration, hypometabolism, and disconnection in multiple brain regions.¹ For instance, early-onset Alzheimer's dementia (EOAD) patients often display more behavioral issues such as agitation, anxiety, irritability, and motor difficulties than those with late-onset Alzheimer's dementia (LOAD).¹ Psychologically, caregiving to neurodegenerative disease patients is challenging, heightening concerns about the risk for poor mental health of caregivers.¹ Multiple longitudinal studies have demonstrated that the rate at which dementia patients experience functional decline is strongly associated with their caregivers' relationship and personality traits.¹ A negative communication style can easily trigger and exacerbate disruptive behaviors, such as depression, anger, and screaming or vice versa.¹ Lastly, the intermediate environment involves lots of physical hardware and social interactions.¹ Yet, dementia patients have a lower stress threshold, which may lead to intensifying mental strain and the emergence of behavioral issues.¹ Therefore, a stable environment or routine living style is highly recommended for dementia patients.¹  

Non-pharmacological management aims to improve quality of life, maximize social functions and enhance cognition, mood, and behaviors.¹ A number of studies have provided evidence that non-pharmacological interventions improve the management of problematic behaviors, significantly reducing the need for neuroleptic medication in patients (19%), and easing the stress experienced by caregivers.¹ The interventions prioritize the provision of patient-oriented therapies tailored to individual needs, as well as sensory stimulation to promote patient alertness and engagement.¹ In addition, psychoeducation and behavioral support are provided to caregivers to help identify any specific stimuli that may trigger disruptive behaviors and manage their expectations.¹ Dr. Rojas summarized 10 principles for the effective management of NPSD, i.e., evaluating medically treatable causes of symptoms; using a structured method to manage NPSD through describing problems, investigating different factors, creating plans and evaluating the results; non-pharmacological interventions should be implemented before pharmacological treatments; adopting an intervention hierarchy in the ascending order of caregiver, environmental, behavioral, pharmacological and physical factors; empowering the caregiver through education, resource connection, and coaching; paying attention to the communication styles and content; prioritizing person-centered care strategies to strengthen patients and honor their choice and value; becoming a structurally competent provider; implementing systems-level and multidisciplinary approaches when possible; and using pharmacological approaches if NPSD causes dangers.¹ 

To incorporate the interventions into daily and clinical settings, the managing method should be well-structured with the DICE approach (i.e., describe, investigate, create, and evaluate), starting from describing the problem via observation, investigating caregiver, environmental and patient factors, then creating and executing plans, and finally evaluating the outcomes.¹