Open access peer-reviewed chapter

Non-Pharmacological Approaches in the Treatment of Dementia

Written By

Grazia D’Onofrio, Daniele Sancarlo, Davide Seripa, Francesco Ricciardi, Francesco Giuliani, Francesco Panza and Antonio Greco

Submitted: 30 March 2016 Reviewed: 13 May 2016 Published: 28 September 2016

DOI: 10.5772/64232

From the Edited Volume

Update on Dementia

Edited by Davide Vito Moretti

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Currently, a pharmacological disease-modifying treatment for dementia is not available, but different non-pharmacological approaches appear to be useful. In this chapter, we describe traditional treatments such as cognitive and emotion-oriented interventions, sensory and multi-sensory stimulation interventions and also potentially alternative interesting options such as behavioural therapy, animal-assisted therapy, home-adaptation therapy and assistive technologies to support patient with dementia. Many non-pharmacological treatments have reported benefits in multiple research studies, but there is a need for further Randomized controlled trials (RCTs) with an adequate sample size to improve the strength of evidence in order to apply these approaches.


  • dementia
  • neuropsychiatric symptoms
  • activities of daily living
  • cognitive and emotion-oriented interventions
  • sensory and multi-sensory stimulation interventions

1. Introduction

Dementia is a term that describes disorders causing cognitive impairment capable to significantly affect functional status [1]. Worldwide, 46.8 million people have dementia, and every year, there are over 9.9 million new diagnosed cases [2], with a total global societal costs of US$ 604 billion in 2010 [2]. Alzheimer’s disease (AD) is the most common form of dementia [3] and represents one of the major causes of disability, dependency, burden and stress of caregivers increasing institutionalization among older people worldwide [4].

This condition also leads to severe social consequences: decreased quality of life and well-being, increased family burdens and healthcare demand and longer term utilization of care facilities that generate very significant impacts on healthcare services demand and consequently costs [5]. The symptoms of dementia are grouped under three main headings: cognitive aspects, functional aspects and neuropsychiatric symptoms (NPSs). Dementia is a disease characterized by a cognitive decline involving one or more cognitive domains (memory and learning, executive function, language, complex attention, perceptual-motor, social cognition, etc.) [6]. The deficits must correspond to a decline from previous level of function and could be severe enough to interfere with daily functions and independence. Memory impairment is one of the main cognitive issues that contribute to the inability to live independently [4, 7, 8]. In the early stages of AD, it limits memory processes and reduces older people’s autonomy in performing more complex daily activities, and it concurrently causes deterioration of emotional control, social behaviour and motivation [4, 6].

The functional aspects can be described in two broad classes: (1) basic activities of daily living or BADL [9, 10] and (2) instrumental activities of daily living or IADL [11]. BADLs are physical tasks essential to maintaining the independence and include the ability to go to the toilet, feed, dress, groom, bathe and ambulate. IADLs are activities typically more cognitively demanding than BADL and include the ability to successfully use the telephone, shop, prepare food, do the housekeeping and laundry, manage medications and finances and use transportation outside of the home (e.g., driving a car, using public transit or riding in a taxi). In the early stage of dementia, most patients are independent with BADL, but they begin to need help with some IADLs [12]. In the moderate phase, cooking, housework and shopping require direct assistance, and BADL require assistance for set-up and safety. Moreover, the presence of NPS could increase anger, frustration and difficulty in communicating needs [13]. As dementia enters the severe stage, independence is progressively lost and caregivers must offer consistent direct care with most if not all BADL [1417].

NPS are common features of Alzheimer’s disease (AD) [18, 19] and are one of the major risk factors for institutionalization [20]. NPS may be correlated to AD independently of cognitive impairment severity or emerge in the course of the illness being a significant cause of a more rapid cognitive decline [21]. It was found that over 80% of AD patients had NPS in the history of the illness [21, 22]. Four separate neuropsychiatric syndromes were identified: hyperactive, psychotic, affective and apathetic [19, 23]. In particular, agitation, euphoria, disinhibition, irritability and aberrant motor behaviour were defined as hyperactive syndrome; delusions, hallucinations and night-time disturbances as psychotic syndrome; depression and anxiety as affective syndrome, and apathy and eating abnormalities as apathetic syndrome.

Currently, there is no effective disease-modifying cure, and treatment is directed mainly to manage the symptoms of dementia [24].

The limited efficacy of the drug therapy and the plasticity of the human brain are the two most important reasons that explain the growing interest in non-pharmacological intervention for dementia patients.

Several non-pharmacological treatments targeting cognitive, functional and neuropsychiatric aspects have been proposed for patients with dementia [25, 26].

This chapter describes the most used non-pharmacological treatment for dementia in according to the best-practice recommendations in the research literature [2730] and the Standards for the Reporting of Diagnostic accuracy studies in dementia (STARDdem) [31].


2. Methods

A narrative review was performed using qualitative data and best-practice recommendations in the research literature [32, 33]. The searches were performed in the MEDLINE, PubMed, EMBASE, CINAHL and PsycINFO databases.

The search queries included ‘dementia’, ‘non-pharmacological treatment’ and ‘cognitive rehabilitation’, and were limited to English language articles.

The inclusion/exclusion criteria used for this review protocol are the following.

Inclusion criteria were as follows: (1) age ≥60 years, (2) diagnosis of dementia according to the criteria of the National Institute on Aging-Alzheimer’s Association (NIAAA) [34], (3) use of non-pharmacological tools to treat the cognitive and functional impairment in dementia and (4) acceptable clinical measures of cognitive impairment, disability, quality of life and global clinical assessments.

Exclusion criteria were as follows: (1) no English editing (because we had no resources for translation) and (2) diagnosis of non-dementia.

Quality of study reporting was assessed using the Standards for the Reporting of Diagnostic accuracy studies in dementia (STARDdem) [35].


3. Cognitive and emotion-oriented interventions

Cognitive and emotion-oriented care approach seeks to improve cognitive, emotional and social functioning by supporting patients with dementia [36]. The treatments commonly used are reminiscence therapy, reality orientation therapy and validation therapy.

3.1. Reminiscence therapy

Reminiscence therapy is a common and widely diffused intervention in dementia care although based on a few high-quality and sufficiently robust studies. Two studies explored group reminiscence [37, 38]. A study evaluated effects on neuropsychiatric and cognitive symptoms [37]. Another reminiscence group intervention [38] evaluated effectiveness in preventing cognitive impairment progression and enhancing affective function. The results showed improvement in most variables including cognition and depression than controls.

3.2. Reality orientation therapy

Reality orientation (RO) is a technique of cognitive stimulation [39, 40]. It entails presenting the patient by continuous memory and orientation information associated with personal environment and issues. Several methods of implementing RO have been explained [4042]. Throughout the treatment sessions, the patient is supported to talk about various arguments linked to his daily routine and recent events. Encouraging the patient to connect socially is a very significant component of the therapy [40, 42, 43]. Following the first publication of a review about RO, interest in the subject increased dramatically and most subsequent articles reported substantial benefits following the use of these strategies [40, 42, 44].

RO focuses on new cognitive stimulation strategies emerged in recent studies. The cognitive stimulation therapy (CST) is an example [40, 45]. Beyond the features assessed in RO, the CST is based also on multi-sensory stimulation and reminiscence [40, 44, 46].

Some reviews about RO confirmed earlier findings of substantial benefits and also identified existing and new areas where further work is required [3941].

3.3. Validation therapy

The validation therapy (VT) was developed stages: to address the shortcomings of other approaches, such as RO, in approaching patients who have more advanced dementia. The VT was the result of an attempt to provide practical solutions for difficulties experienced by patients and caregivers.

Important characteristics of VT include: means of classifying behaviours, provision of simple, practical techniques that help restore dignity, provision of an empathic listener, respect and empathy for older adults with dementia and acceptance of the person’s reality [47].

The way in which these rules are applied to provide specific interventions depends on the dementia severity categorized into mal orientation, time confusion, repetitive motion and vegetation. Each stage is recognized through defined cognitive and behavioural features and defined VT interventions address the various cognitive and neuropsychiatric characteristics showed by dementia people at each stage [47]. Various observational studies have indicated that the application of VT determine positive effects about amount and duration of interactions that participants are able to make during validation groups session [48, 49]. Though, other studies showed no significant effects of VT [50].


4. Sensory and multi-sensory stimulation interventions

Sensory stimulation and multi-sensory stimulation refer to a variety of techniques used to stimulate the senses in order to increase alertness and reduce agitation [51]. Sensory stimulation includes auditory, visual, olfactory, tactile, taste and kinaesthetic stimulation [52, 53]. Several studies examined sensorial and multi-sensorial interventions. In this chapter, seven therapy types were identified.

4.1. Art therapy

Art therapy is the therapeutic use of art making within a professional relationship. It has been suggested as a treatment for people with dementia as it has the potential to provide meaningful stimulation, improve social interaction and improve levels of self-esteem [54]. Activities such as drawing and painting are thought to provide individuals the opportunity for self-expression and the chance to exercise some choices in terms of the colours and themes of their creations.

4.2. Music therapy

Music therapy is defined as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional [55]. Two studies showed the effect of music on neuropsychiatric symptoms [56, 57]. It was tested a live-music intervention on decreasing anxiety and agitation [55]. Results showed no significant differences in anxiety and agitation. However, a study [56] showed a statistically significant decrease of the agitation in a group music-listening intervention.

4.3. Occupational therapy

The primary focus of occupational therapy (OT) is to improve patients’ ability to perform activities of daily living, promote independence, reduce caregiver burden and ultimately improve quality of life.

OT offers interventions associated with awareness of self-care, leisure activities, occupational identity and productivity [58]. Studies showed an association between cognitive impairment and occupational performance [59, 60]. Therefore, patients with dementia can be assisted through OT trying to preserve an adequate performance level in BADL and IADL [61]. Furthermore, caregivers can adopt OT techniques, in the family or institution, to stimulate patient performing daily activities, preventing disruptive behaviour, wandering and aggression.

4.4. Aromatherapy

Aromatherapy is the fastest growing of all complementary therapies, in terms of public interest [62]. It aids interaction while providing a sensory experience. Aromatherapy appears to have several advantages over the pharmacological treatments used for dementia [63]. It seems to be well tolerated in comparison with sedative or neuroleptic medication [63]. The two essential oils used in aromatherapy for dementia patients are extracted from lavender and Melissa balm and could be administered in numerous methods such as bathing, inhalation, massage and topical application in cream [63]. Aromatherapy can be addressed to patients with several behaviours. Recent controlled trials showed significant reductions in agitation, with excellent compliance and tolerability [6365].

4.5. Bright-light therapy

Bright light therapy (BLT) consists of exposure to daylight or specific wavelengths of light using polychromatic polarised light, laser, light-emitting diodes, fluorescence lamps, dichroic lamps or very bright, full-spectrum light. Four studies tested the effect of BLT on behavioural symptoms [6669]. Two studies compared the effect of morning BLT and afternoon/evening BLT with normal light [66, 67]. Other studies compared one single type of BLT with usual light [66], and no differences were found between morning and evening. Limited evidence of reduction in agitation and aggression among those receiving BLT was found [67, 70].

4.6. Activity therapy

Activity therapy (AT) implicates recreation activities such as dance, sport and drama. It was found that physical exercise can have health benefits for dementia patients, reducing the number of falls and improving mental health, sleep [63, 70] and mood [71]. In addition, it was found that daytime exercise aided to decrease daytime agitation and night-time restlessness [63, 72]. Perrin described an interesting approach to dance therapy: he employed a form of dance known as ‘jabadeo’, which allows the patients to engage with each other in interactive movements [63, 73].

4.7. Snoezelen multi-sensory stimulation

Snoezelen is a multi-sensory setting for implementation of several sensory-based tools. Snoezelen offers sensory stimuli to primary senses of hearing, touch, sight, smell and taste, by the use of music, odour of essential oils, lighting effects and tactile surfaces [74]. Several studies define snoezelen approach as a support therapy for dementia patients [75]. The goals of such therapy are to promote positive behaviours and to reduce maladaptive behaviours [76, 77].

Over the past decade, the clinical application of Snoezelen has been extended from the field of learning disability to dementia care. Its use resides in providing a sensory environment that capitalizes on the residual sensorimotor abilities of dementia patients. Moreover, encouraging results were obtained in the area of promoting adaptive behaviours [78]. In practice, snoezelen capitalize on the residual sensorimotor abilities of dementia sufferers and present a few attentional and intellectual demands [76].


5. Other interventions

5.1. Behavioural therapy

Traditionally, behavioural therapy has been based on principles of conditioning and learning theory using strategies aimed at suppressing or eliminating challenging behaviours. More recently, positive programming methodologies [79] have used non-aversive methods in helping to develop more functional behaviours. Moniz-Cook suggests that behavioural analysis is often the starting point of most other forms of therapeutic intervention in this area [80] and can be wholly consistent with person-centred care. Behavioural therapy requires a period of detailed assessment in which the triggers, behaviours and reinforcers are observed and their relationships made clear to the patient. The therapists use chart or diary to collect information about the behavioural symptoms, and interventions are based on an analysis of these findings.

For Emerson, planning an intervention should be focussed on three key features: identifying the individual’s preferences; changing the context in which the behaviour occurs; and using reinforcement strategies and schedules that reduce the behaviour [63, 81].

A few studies showed the efficacy of behavioural in the context of dementia [63, 82]. There is some evidence of successful reductions in wandering, incontinence and other forms of stereotypical behaviours [83].

5.2. Animal-assisted therapy

Animal-assisted therapy (AAT) most commonly involves interaction between a patient and a trained animal, facilitated by a human handler, with a therapeutic goal such as providing relaxation and pleasure, or incorporating activities into physical therapy or rehabilitation. The therapeutic effect has been described by Baun and McCabe with reference to the stage of dementia and the positive effect on caregivers [84]. A review showed that AAT may ameliorate NPS in patients with dementia [85].

5.3. Home adaptation therapy

Home modifications for patients with dementia should promote safety for the patient and peace of mind for the caregiver. The modifications allow patients with dementia to receive ongoing care in the least restrictive environment possible and may be implemented as the need arises [86]. Home modifications for patients with dementia are associated with improved caregiver effectiveness and less caregiver upset [87].

5.4. Assistive technologies

In recent years, there have been significant innovations in the application of assistive technologies (ATs) to support healthcare for patients with dementia. These technologies can be used by the patients with dementia, by the caregivers, and can run automatically (the so-called ‘ambient intelligence’) [88].

AT applications have the potential to support aging in place for patients with dementia, and they range from internet-based information and support groups to robotic companions comprising also the use of smartphones to report symptoms [8991].

Several studies describe the responses of caregivers and patients with dementia (PWD) to technology [9294]. In general, the objective of AT is to allow people to remain more independent and reside at home safely [9193]. In an another study, it was found that involving the patients with dementia in the process of developing technological applications enhanced usability and acceptability and contributed to a sense of empowerment [95].


6. Conclusion

Great efforts have been made to develop strategies to improve the quality of life of dementia patients. A shared feature is the need to work with systems (families, professional careers, organisations, etc.) [63]. Care staff and families are regularly integral to treatment strategies and are essential in obtaining reliable information and constructing appropriate interventions [63]. It is evident, therefore, that training of carers (both professional and family) is an important part of most treatment programmes. A study suggested that the most common interventions for psychological and behavioural symptoms of dementia were not necessarily specific therapies but working with carers to change the attitudes and behaviour of those in their care [96]. The field of dementia care is growing, with an increasing number of articles about psychosocial interventions [63]. Though, there is a fundamental limitation within the current literature that clearly requires addressing. A care plan that focused on non-pharmacological interventions is considered best practice as the first-line management of most NPS of dementia. They can significantly improve quality of life and satisfaction of patients with dementia and their caregivers.


  1. 1. D’Onofrio G, Sancarlo D, Addante F, Ciccone F, Cascavilla L, Paris F, Picco M, Nuzzaci C, Elia AC, Greco A, Chiarini R, Panza F, Pilotto A. Caregiver burden characterization in patients with Alzheimer’s disease or vascular dementia. Int J Geriatr Psychiatry. 2015;30(9):891–899.
  2. 2. World Health Organization. Dementia: A Public Health Priority, 2012. Available from: 8_eng.pdf. Accessed May 31, 2015.
  3. 3. Cummings JL. Alzheimer’s disease. N Engl J Med. 2004;351:56–67.
  4. 4. Schultz R, Williamson GH. A 2-year longitudinal study of depression among Alzheimer’s caregivers. Psychol Aging. 1991;6:569–578.
  5. 5. Seelye A, Schmitter-Edgecombe M, Das B, Cook DJ. Application of cognitive rehabilitation theory to the development of smart prompting technologies. IEEE Rev Biomed Eng. 2012;5:29–44.
  6. 6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Arlington: American Psychiatric Association, 2013.
  7. 7. Grady C, Craik F. Changes in memory processing with age. Curr Opin Neurobiol. 2000;10(2):224–231.
  8. 8. Schmitter EM, Woo E. Characterizing multiple memory deficits and their relation to everyday functioning in individuals with mild cognitive impairment. Neuropsychology. 2009;23(2):168–177.
  9. 9. Katz S, Downs TD, Cash HR, Grotz RC. Progress in the development of an index of ADL. Gerontologist. 1970;10:20–30.
  10. 10. Lawton MP. Aging and performance of home tasks. Hum Factors. 1990;32(5):527–536.
  11. 11. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–186.
  12. 12. Wattmo C, Wallin AK, Minthon L. Progression of mild Alzheimer’s disease: knowledge and prediction models required for future treatment strategies. Alzheimer’s Res Ther. 2013;5:44.
  13. 13. Nowrangi MA, Lyketsos CG, Rosenberg PB. Principles and management of neuropsychiatric symptoms in Alzheimer’s dementia. Alzheimer’s Res Ther. 2015;7:12.
  14. 14. Fraga FJ, Falk TH, Kanda PAM, Anghinah R. Characterizing Alzheimer’s disease severity via resting-awake EEG amplitude modulation analysis. PLoS One. 2013;8(8):e72240.
  15. 15. Futrell M, Melillo KD, Remington R, Schoenfelder DP. Wandering. J Gerontol Nurs. 2010;36(2):6–16.
  16. 16. Eshkoor SA, Hamid TA, Nudin SSH, Mun CY. A research on functional status, environmental conditions, and risk of falls in dementia. Int J Alzheimer’s Dis. 2014;2014:6.
  17. 17. Volicer L, van der Steen JT. Outcome measures for dementia in the advanced stage and at the end of life. Adv Geriatr. 2014;2014:10.
  18. 18. Mega MS, Cummings JL, Fiorello T, Gornbein J. The spectrum of behavioral changes in Alzheimer’s disease. Neurology. 1996;46:130–135.
  19. 19. Aalten P, Verhey FR, Boziki M, Bullock R, Byrne EJ, Camus V, Caputo M, Collins D, De Deyn PP, Elina K, Frisoni G, Girtler N, Holmes C, Hurt C, Marriott A, Mecocci P, Nobili F, Ousset PJ, Reynish E, Salmon E, Tsolaki M, Vellas B, Robert PH. Neuropsychiatric syndromes in dementia. Results from the European Alzheimer Disease Consortium: part I. Dement Geriatr Cogn Disord. 2007;24:457–463.
  20. 20. Steele C, Rovner B, Chase GA, Folstein M. Psychiatric symptoms and nursing home placement of patients with Alzheimer’s disease. Am J Psychiatry. 1990;147:1049–1051.
  21. 21. Finkel SI, Costa E, Silva J, Cohen G, Miller S, Sartorius N. Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment. Int Psychogeriatr. 1996;8:497–500.
  22. 22. Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. JAMA. 2002;288:1475–1483.
  23. 23. Aalten P, Verhey FR, Boziki M, Brugnolo A, Bullock R, Byrne EJ, Camus V, Caputo M, Collins D, De Deyn PP, Elina K, Frisoni G, Holmes C, Hurt C, Marriott A, Mecocci P, Nobili F, Ousset PJ, Reynish E, Salmon E, Tsolaki M, Vellas B, Robert PH. Consistency of neuropsychiatric syndromes across dementias: results from the European Alzheimer Disease Consortium: part II. Dement Geriatr Cogn Disord. 2008;25:1–8.
  24. 24. Atri A. Effective pharmacological management of Alzheimer’s disease. Am J Manag Care. 2011;17:S346–S355.
  25. 25. Acevedo A, Loewenstein DA. Non pharmacological cognitive interventions in aging and dementia. J Geriatr Psychiatry Neurol. 2007;20:239–249.
  26. 26. D’Onofrio G, Sancarlo D, Addante F, Ciccone F, Cascavilla L, Paris F, Elia AC, Nuzzaci C, Picoco M, Greco A, Panza F, Pilotto A. A pilot randomized controlled trial evaluating an integrated treatment of rivastigmine transdermal patch and cognitive stimulation in patients with Alzheimer’s disease. Int J Geriatr Psychiatry. 2015;30(9):965–975.
  27. 27. Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy. 2005;10:45–53.
  28. 28. Hannes K, Macaitis K. A move to more systematic and transparent approaches in qualitative evidence synthesis: update on a review of published papers. Qual Res. 2012;12:402–442.
  29. 29. Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009;9:59.
  30. 30. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26:91–108.
  31. 31. Noel-Storr AH, McCleery JM, Richard E, Ritchie CW, Flicker L, Cullum SJ, Davis D, Quinn TJ, Hyde C, Rutjes AW, Smailagic N, Marcus S, Black S, Blennow K, Brayne C, Fiorivanti M, Johnson JK, Köpke S, Schneider LS, Simmons A, Mattsson N, Zetterberg H, Bossuyt PM, Wilcock G, McShane R. Reporting standards for studies of diagnostic test accuracy in dementia: The STARDdem Initiative. Neurology. 2014;83(4):364–373.
  32. 32. Collings AJ, Fauser CJMB. Balancing the strengths of systematic and narrative reviews. Hum Reprod Update. 2005;11(2):103–104.
  33. 33. Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy. 2005;10:45–53.
  34. 34. McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR Jr, Kawas CH, Klunk WE, Koroshetz WJ, Manly JJ, Mayeux R, Mohs RC, Morris JC, Rossor MN, Scheltens P, Carrillo MC, Thies B, Weintraub S, Phelps CH. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7:263–269.
  35. 35. Noel-Storr AH, McCleery JM, Richard E, Ritchie CW, Flicker L, Cullum SJ, Davis D, Quinn TJ, Hyde C, Rutjes AW, Smailagic N, Marcus S, Black S, Blennow K, Brayne C, Fiorivanti M, Johnson JK, Köpke S, Schneider LS, Simmons A, Mattsson N, Zetterberg H, Bossuyt PM, Wilcock G, McShane R. Reporting standards for studies of diagnostic test accuracy in dementia: the STARDdem Initiative. Neurology. 2014;83(4):364–373.
  36. 36. Finnema E, Dröes RM, Ribbe M, Tilburg WV. The effects of emotion-oriented approaches in the care for persons suffering from dementia: a review of the literature. Int J Geriatr Psychiatry. 2000;15:141–161.
  37. 37. Ito T, Meguro K, Akanuma K, Ishii H, Mori E. A randomized controlled trial of the group reminiscence approach in patients with vascular dementia. Dement Geriatr Cogn. 2007;24:48–54.
  38. 38. Wang J. Group reminiscence therapy for cognitive and affective function of demented elderly in Taiwan. Int J Geriatr Psychiatry. 2007;22:1235–1240.
  39. 39. Choi J, Twamley EW. Cognitive rehabilitation therapies for Alzheimer’s disease: a review of methods to improve treatment engagement and self-efficacy. Neuropshycol Rev. 2013;23(1):48–62.
  40. 40. Camargo CH, Justus FF, Retzlaff G. The effectiveness of reality orientation in the treatment of Alzheimer’s disease. Am J Alzheimers Dis Other Demen. 2015;30(5):527–532.
  41. 41. Aguirre E, Woods RT, Spector A, Orrell M. Cognitive stimulation for dementia: a systematic review of the evidence of effectiveness from randomized controlled trials. Ageing Res Rev. 2013;12(1):253–262.
  42. 42. Spector A, Orrell M, Woods B. Cognitive Stimulation Therapy (CST): effects on different areas of cognitive function for people with dementia. Int J Geriatr Psychiatry. 2010;25(12):1253–1258.
  43. 43. Spector A, Davies S, Bob Woods, Orrell M. Reality orientation for dementia: a systematic review of the evidence of effectiveness from randomized controlled trials. Gerontologist. 2000;40(2):206–212.
  44. 44. Spector A, Woods B, Orrell M. Cognitive stimulation for the treatment of Alzheimer’s disease. Expert Rev Neurother. 2008;8(5):751–757.
  45. 45. Breuil V, De Rotrou J, Forette F. Cognitive stimulation of patients with dementia: preliminary results. Int J Geriatr Psychiatry. 1994;9:211–217.
  46. 46. Clare L, Woods RT. Cognitive training and cognitive rehabilitation for people with early-stage Alzheimer’s disease: a review. Neuropsychol Rehabil. 2004;14(4):385–401.
  47. 47. Feil N. Validation therapy. Geriatr Nurs. 1992;13:129–133.
  48. 48. Babins LH. Conceptual analysis of validation therapy. Int J Aging Hum Dev. 1998;26:161–168.
  49. 49. Deponte A, Missan R. Effectiveness of validation therapy (VT) in group: preliminary results. Arch Gerontol Geriatr. 2007;44:113–117.
  50. 50. Scanland SG, Emershaw EL. Reality orientation and validation therapy: dementia, depression, and functional status. J Gerontol Nurs. 1993;19:7–11.
  51. 51. Gammeltoft BC. Invisible Handicaps among Persons Suffering from Brain Injury. Høng: Forlaget FCT, Eligius; 2005.
  52. 52. Vozzella S. Sensory stimulation in dementia care: why it is important and how to implement it. Top Geriatr Rehabil. 2007;23(2):102–113.
  53. 53. Baker R, Bell S, Baker E, Gibson S. A randomized controlled trial of the effect of multi-sensory stimulation (MSS) for people with dementia. Br J Clin Psychol. 2001;40:81–96.
  54. 54. Killick J, Allan K. The arts in dementia care: tapping a rich resource. J Dementia Care. 1999;7:35–38.
  55. 55. American Music Therapy Association. What is music therapy? 2005. Available from:
  56. 56. Cooke M, Moyle W, Shum D, Harrison S, Murfield J. A randomized controlled trial exploring the effect of music on quality of life and depression in older people with dementia. J Health Psychol. 2010;15:765–776.
  57. 57. Lin Y, Chu H, Yang CY, Chen CH, Chen SG, Chang HJ, Hsieh CJ, Chou KR. Effectiveness of group music intervention against agitated behavior in elderly persons with dementia. Int J Geriatr Psychiatry. 2011;26:670–678.
  58. 58. Whiteford G, Fossey E. Occupation: the essential nexus between philosophy, theory and practice. Aust Occup Ther J. 2002;49(1):1–2.
  59. 59. Nygård L, Amberla K, Bernspång B, Almkvist O, Winblad B. The relationship between cognition and daily activities in cases of mild Alzheimer’s disease. Scand J Occup Ther. 1998;5:160–166.
  60. 60. Ohman A, Nygard L, Kottorp A. Occupational performance and awareness of disability in mild cognitive impairment or dementia. Scand J Occup Ther. 2011;18:133–142.
  61. 61. Nygård L. Responses of persons with dementia to challenges in daily activities: A synthesis of findings from empirical studies. Am J Occup Ther. 2004;58:435–445.
  62. 62. Burns A, Byrne J, Ballard C, Holmes C. Sensory stimulation in dementia. An effective option for managing behavioural problems. BMJ. 2002;325:1312–1313.
  63. 63. Douglas S, James I, Ballard C. Non-pharmacological interventions in dementia. BJPsych Adv. 2004;10:171–177.
  64. 64. Ballard CG, O’Brien J, Reichelt K, Perry EK. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double blind, placebo controlled trial. J Clin Psychiatry. 2002;63:553–558.
  65. 65. Holmes C, Ballard C. Aromatherapy in dementia. Adv Psychiatr Treat. 2004;10(4):296–300.
  66. 66. Lyketsos CG, Lindell VL, Baker A, Steele C. A randomized, controlled trial of bright light therapy for agitated behaviors in dementia patients residing in long-term care. Int J Geriatr Psychiatry. 1999;14:520–525.
  67. 67. Ancoli-Israel S, Martin JL, Gehrman P, Shochat T, Corey-Bloom J, Marler M, Nolan S, Levi L. Effect of light on agitation in institutionalized patients with severe Alzheimer disease. Am J Geriatr Psychiatry. 2003;11:194–203.
  68. 68. Dowling GA, Graf CL, Hubbard EM, Luxenberg JS. Light treatment for neuropsychiatric behaviors in Alzheimer’s disease. West J Nurs Res. 2007;29:961–975.
  69. 69. Burns A, Allen H, Tomenson B, Duignan D, Byrne J. Bright light therapy for agitation in dementia: a randomized controlled trial. Int Psychogeriatr. 2009;21:711–721.
  70. 70. King A, Oman R, Brassington G, Bliwise DL, Haskell WL. Moderate intensity exercise and self-rated quality of sleep in older adults. A randomised controlled trial. JAMA. 1997;277:32–37.
  71. 71. Young A, Dinan S. ABC of sports medicine. Fitness for older people. BMJ. 1994;309:331–334.
  72. 72. Alessi C, Yoon E, Schnelle J, Al-Samarrai NR, Cruise PA. A randomised trial of a combined physical activity and environment intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc. 1999;47:784–791.
  73. 73. Perrin T. Lifted into a world of rhythm and melody. J Dementia Care. 1998;6:22–24.
  74. 74. Pinkney L. A comparison of the Snoezelen environment and a music relaxation group on the mood and behaviour of patients with senile dementia. Br J Occup Ther. 1997;60(5):209–218.
  75. 75. Burns I, Cox H, Plant H. Leisure or therapeutics? Snoezelen and the care of older persons with dementia. Int J Nurs Pract. 2000;6:118–126.
  76. 76. Baker R, Bell S, Baker E, Gibson S, Holloway J, Pearce R, Dowling Z, Thomas P, Assey J, Wareing LA. A randomized controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia. Br J Clin Psychol. 2001;40(1):81–96.
  77. 77. Slevin E, McClelland A. Multisensory environments: are they therapeutic? A single subject evaluation of the clinical effectiveness of a multisensory environment. J Adv Nurs. 1999;8(1):48–56.
  78. 78. Kovach CR. Sensoristasis and imbalance in persons with dementia. J Nurs Scholorsh. 2000;32(4):379–384.
  79. 79. La Vigna G, Donnellan A. Alternative to Punishment: Solving Behaviour Problems with Non-aversive Strategies. New York: Irvington, 1986.
  80. 80. Moniz-Cook E, Agar S, Silver M, Woods R, Wang M, Elston C, Win T. Can staff training reduce behavioural problems in residential care for the elderly mentally ill? Int J Geriatr Psychiatry. 1998;13:149–158.
  81. 81. Emerson E, Thompson S, Reeves D, Henderson D, Robertson J. Descriptive analysis of multiple response topographies of challenging behaviour across two settings. Res Dev Disabil. 1995;16:301–329.
  82. 82. Burgio L, Fisher S. Application of psychosocial interventions for treating behavioural and psychological symptoms of dementia. Int Psychogeriatr. 2000;12(1):351–358.
  83. 83. Woods RT. Psychological Problems of Ageing. Chichester: John Wiley and Sons, 1999.
  84. 84. Baun MM, McCabe BW. Companion animals and persons with dementia of the Alzheimer’s type: therapeutic possibilities. Am Behav Sci. 2003;47:42–51.
  85. 85. Filan SL, Llewellyn-Jones RH. Animal-assisted therapy for dementia: a review of the literature. Int Psychogeriatr. 2006;18(4):597–611.
  86. 86. U.S. Department of Health and Human Services Public Health Service. National Institutes of Health, National Institute on Aging. Home safety for people with Alzheimer’s disease. Available from: file:///C:/Documents%20and%20Settings/tir03222/Documenti/Downloads/home_safety_for_people_with_alzheimers_disease_2.pdf. Accessed May 31, 2015.
  87. 87. Gitlin LN, Corcoran M, Winter L, Boyce A, Hauck WW. A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia. Gerontologist. 2001;41(1):4–14.
  88. 88. Cook DJ, Augustob JC, Jakkulaa VR. Ambient intelligence: technologies, applications, and opportunities. Pervasive Mob Comput. 2009;5(4):277–298.
  89. 89. Czaja SJ, Rubert MP. Telecommunications technology as an aid to family caregivers of persons with dementia. Psychosom Med. 2002;64:469–476.
  90. 90. Powell J, Chiu T, Eysenbach G. A systematic review of networked technologies supporting carers of people with dementia. J Telemed Telecare. 2008;14(3):154–156.
  91. 91. Steis M, Prabhu V, Kolanowski A, Kang Y, Bowles KH, Fick D, Evans L. Detection of delirium in community-dwelling persons with dementia. Online J Nurs Inform. 2012;16(1) Available at
  92. 92. Pot AM, Willemse BM, Horjus S. A pilot study on the use of tracking technology: feasibility, acceptability, and benefits for people in early stages of dementia and their informal caregivers. Aging Ment Health. 2012;16(1):127–134.
  93. 93. Steele R, Lo A, Secombe C, Wong YK. Elderly persons’ perception and acceptance of using wireless sensor networks to assist healthcare. Int J Med Inform. 2009;78(12):788–801.
  94. 94. van Hoof J, Kort HS, Rutten PG, Duijnstee MS. Ageing-in-place with the use of ambient intelligence technology: perspectives of older users. Int J Med Inform. 2011;80(5):310–331.
  95. 95. Span M, Hettinga M, Vernooij-Dassen M, Eefsting J, Smits C. Involving people with dementia in the development of supportive IT applications: a systematic review. Ageing Res Rev. 2013;12(2):535–551.
  96. 96. Bird M, Llewellyn-Jones R, Smithers H, Korten A. Psychosocial Approaches to Challenging Behaviour in Dementia: A Controlled Trial. Report to the Commonwealth Department of Health and Ageing. Canberra: CDHA, 2002.

Written By

Grazia D’Onofrio, Daniele Sancarlo, Davide Seripa, Francesco Ricciardi, Francesco Giuliani, Francesco Panza and Antonio Greco

Submitted: 30 March 2016 Reviewed: 13 May 2016 Published: 28 September 2016