International Psychogeriatrics

Review Article

Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies, 1998–2008: a systematic literature review

Karan S. Kvernoa1 c1, Betty S. Blacka2a5a6, Marie T. Nolana3a6 and Peter V. Rabinsa2a4a5a6

a1 The University of Maryland School of Nursing, Baltimore, Maryland, U.S.A.

a2 The Johns Hopkins Medical Institutions Department of Psychiatry and Behavioral Sciences, Baltimore, Maryland, U.S.A.

a3 The Johns Hopkins University School of Nursing, Baltimore, Maryland, U.S.A.

a4 The Johns Hopkins Medical Institutions Department of Medicine, Baltimore, Maryland, U.S.A.

a5 The Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, U.S.A.

a6 The Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, U.S.A.


Background: Advanced dementia is characterized by severe cognitive and functional impairments that lead to almost total dependency in self-care. Neuropsychiatric symptoms (NPS) are common in advanced dementia, diminishing quality of life and increasing the care burden. The challenge for health care providers is to find safe and effective treatments. Non-pharmacological interventions offer the potential for safer alternatives to pharmacotherapy, but little is known about their efficacy. This review evaluates the published literature on non-pharmacological interventions for treating NPS in advanced dementia.

Methods: A literature search was undertaken to find non-pharmacological intervention studies published between 1998 and 2008 that measured NPS outcomes in individuals diagnosed with advanced dementia. Strict inclusion criteria initially required that all study participants have severe or very severe dementia, but this range was later broadened to include moderately severe to very severe stages.

Results: Out of 215 intervention studies, 21 (9.8%) specifically focused on treatments for individuals with moderately severe to very severe dementia. The studies provide limited moderate to high quality evidence for the use of sensory-focused strategies, including aroma, preferred or live music, and multi-sensory stimulation. Emotion-oriented approaches, such as simulated presence may be more effective for individuals with preserved verbal interactive capacity.

Conclusions: Most studies of interventions for dementia-related NPS have focused on individuals with mild to moderate cognitive impairment. Individuals with severe cognitive impairment do not necessarily respond to NPS treatments in the same manner. Future studies should be specifically designed to further explore the stage-specific efficacy of non-pharmacological therapies for patients with advanced dementia. Areas of particular need for further research include movement-based therapies, hands-on (touch) therapies, and interventions that can be provided during personal care routines. Interventions appear to work best when they are tailored to balance individual arousal patterns.

(Received November 05 2008)

(Revised January 06 2009)

(Revised April 27 2009)

(Accepted April 28 2009)

(Online publication July 09 2009)


c1 Correspondence should be addressed to: Karan S. Kverno, PhD, PMHNP, University of Maryland School of Nursing, Department of Family and Community Health, 655 W. Lombard St., Suite 555B, Baltimore, MD 21201, U.S.A. Phone: +1 410-706-7556; Fax: +1 410-706-0253. Email: