The psychosocial management of dementia includes social and environmental approaches to the care of patients with dementia, as well as psychosocial and behavioural approaches. A useful classification of behaviours has been devised, dividing them into three categories:

These have been linked to different causes. For example, physical aggression most commonly occurs during personal care and may be a function of the nature of the interaction between the carer and the person with dementia. Finding alternative approaches to personal care can prove useful.

In contrast, verbal agitation occurs most commonly when the person is alone or during personal care and, as such, may be linked to pain, discomfort or a need for social contact. The extent of undetected pain in people with dementia is well-documented, so appropriate care for behaviour may include medical treatment for pain. Simulated presence therapy addresses the person’s social need by providing an audiotape of a close relative talking about shared memories. This has led to decreased agitation for some patients [Woods, 1995].

Physically nonaggressive behaviours, such as wandering, are associated with stimulation seeking. Providing the person with something to do has been shown to reduce behavioural aspects of dementia [Teri, 1991, Rovner, 1996].

A strong association exits between the lack of meaningful activity and the presence of depression [Rabinovich, 1992] and challenging behaviours [Cohen-Mansfield, 1998].

Therapeutic activity programmes have been used to decrease disruptive behaviour by providing engagement in pleasant activities [Teri, 1991]. Rovner et al. randomly assigned agitated residents to either a treatment or control condition. In the treatment condition residents attended an activity programme where the goal was physical, mental and social stimulation which included exercise, music, crafts, relaxation and reminiscence [Rovner, 1996]. In addition, each resident’s medication was reviewed and psychiatric input received. Residents in the treatment groups showed significant reduction in behavioural disturbance and use of psychotropic drugs and restraints.

Physical designs – appropriate physical designs can minimize decline and improve functioning in patients with dementia. For example, low lighting has been linked to confusion and agitation [Cohen-Mansfield, 1998, Cohen-Mansfield, 1986], whereas noise is linked to agitation and poor functional performance. Changing these factors may improve the patient’s condition. The potential exists to prolong independence, promote sense of safety and prevent development of ‘challenging behaviours’.

Functional competence/daily living skills – there is a growing body of evidence that suggests that appropriate interventions can help maintain daily living skills, at least for those with mild to moderate impairments [Lawton, 2000]. For example, in a nursing home setting, residents get the most social contact from staff by exhibiting dependent behaviours and interventions have been designed to reverse this dynamic [Baltes, 1992, Baltes, 1994]. Beck et al. taught nursing assistants to use strategies to promote independence in dressing with 90 cognitively impaired nursing home residents [Beck, 1997]. During the first week of treatment, 75% of residents improved one or more levels of dressing independence. After six weeks of intervention they found a significant improvement in dressing independence.

Communication and social interaction – psychological, behavioural and environmental interventions are used to improve memory, communication, activities of daily living and emotional well being [Lawton, 2000, Woods, 2002]. Most of these interventions rely on carers to initiate or respond in ways that compensate for deficits and support the abilities of the person with dementia. There are several ways that families and carers can affect a person’s quality of life. For example, encouraging carers to use memory books increases the amount and quality of social interaction with people, even those who have advanced dementia [Bourgeois, 1996]. In this support framework, those with advanced dementia demonstrate increased verbal interaction.

Verbal prompts and cues can help people with dementia regain and maintain everyday abilities such as dressing. Using Reality Orientation (RO), where the carer provides the person with visual and verbal cues in order to help with orientation to time, place or person improves behaviour and cognition [Spector, 1999]. This orientation can take place either in groups or in one-on-one interactions.

Carers can also assist people with dementia to recall events from their past, facilitated by the use of personalized aids, such as photos or memorabilia, either in one-to-one or in group sessions.

Validation therapy affirms, rather than confronts, a person’s sense of reality and makes an effort to compensate for a person’s difficulty in communicating by addressing the underlying meaning of speech and behaviour. The listener ‘validates’ what is said by listening to the emotional meaning rather than the factual content of what is said. This can be used in group settings or during one-on-one interactions. However, evidence of the effectiveness of validation therapy is largely anecdotal.

Psychoeducational interventions are being used in clinical settings with people with dementia and their families. They are used to help people adapt both emotionally and behaviourally to living with cognitive symptoms [Woods, 1999]. These include cognitive rehabilitation and memory training, psychotherapy [Frazer, 2000] and peer support groups [Yale, 1995].

Helping caregivers is a critical component of comprehensive dementia care. Counselling, training programs and continued support can decrease caregiver distress and depression and delay nursing home admission [Brodarty, 1989; Brodarty, 1997; Mittelman, 1996; Brodarty, 2003]. Referral to the Alzheimer's Association or Society is good procedure, national contact numbers can be found by going to the Alzheimer's Society website (www.alzheimers.org.uk). In the United Kingdom telephone: +44 20 7306 0606. International contact numbers can be found by going to the Alzheimer’s Disease International website (www.alz.co.uk). In the USA telephone: +1 312 335-8700 (www.alz.org).