Non-Pharmacological Approaches for Alleviating Distress in Dementia Care

Gary Mitchell, Dementia Care Advisor and Joanne Agnelli, Dementia Services Quality Manager for Four Seasons Health Care,  will be leading the next ENB TWITTER chat on Wednesday 21st January 8-9pm UK time, and will focus on non-pharmacological approaches for alleviating distress in dementia care. In order to participate in the EBN twitter chat, if you do not already have one, you require a Twitter account, you can create an account at Once you have an account contributing is straightforward; you can follow the discussion by searching for links to #ebnjc @EBNursingBMJ, or better still, create a tweet (tweets are text messages limited to 140 characters) to ENB the journal @EBNursingBMJ and add #ebnjc (the EBN chat hashtag) at the end of your tweet, this allows everyone taking part to view your tweets.

Estimates suggest that feelings of distress occurs in almost 80% of people living with dementia (James et al, 2008). Traditionally the management of distress was through the use pharmacological intervention, like Risperidone, Olanzapine, Quetiapine (Sink et al, 2005). While the use of these medications may be appropriate for some people living with dementia, the use of non-pharmacological approaches as a means to reduce distress is recommended because they can be more dignified and are in keeping with the ethos of person-centred care, and are more cost-effective when compared to the prescription and administration of medications (NICE, 2011). The approaches of reminiscence, reality orientation, validation, music therapy, horticultural therapy, doll therapy and pet therapy have proved popular techniques when considering non-pharmacological approaches for alleviation of distress in dementia care.

Reminiscence Therapy – focuses on assisting the person living with dementia to relive positive past experiences of their life and may be related to their family life, their wedding, the places they used to visit or the activities they used to carry out at work.

Reality Orientation – is about re-orientating the person living with dementia to their current environment. Orientation can be achieved directly through open communication between healthcare professionals and people living with dementia. In addition aids such as clocks, calendars, specialist dementia signage and personalisation of living spaces can also aid in assisting people living with dementia to recognise their surroundings.

Validation Therapy – centres on the idea of acceptance of another person’s reality. The clinical manifestations of dementia mean that sometimes people living with the condition may feel they are in another time or place. When healthcare professionals fail to validate a person’s feelings or reality this can intensify the level of distress a person is experiencing.

Music Therapy – is categorised as a sensory therapy which has generated positive results in relation to enhancement of wellbeing and alleviation of distress in dementia care. The personalisation of music therapy is an important element to consider so as to ensure that the person living with dementia actually finds the music, either being played or being listened to, as therapeutic.

Horticultural Therapy – or garden therapy has been emerging as a popular therapy in recent years. Horticultural therapy can be directed by healthcare professionals in a garden area and activities may be guided, for example the potting of plants, the sewing of seeds or the feeding of birds.

Doll Therapy – arguably the most contentious non-pharmacological approach on offer, doll therapy is often unstructured and engagement with the doll could be any number of things to include: talking to the doll, cuddling the doll, dressing the doll, playing with the doll or feeding the doll Benefits to doll therapy include: greater levels of wellbeing through improvement in communication, maintaining a safe environment and personal care. It should be noted that while there are a plethora of benefits associated with doll therapy, there are number of things that healthcare professionals need to consider in relation to doll therapy, the most of important of these is arguably ethical conduct as some critics of doll therapy believe it to be infantile, in that people living with dementia are encouraged to play with dolls like children.

Pet Therapy – is a popular but sometimes difficult intervention to source given the practicalities. Pet therapy or animal assisted therapy has shown positive results in people living with dementia who are fond of animals. The most popular animal used in this intervention is a dog.

Personalisation – Arguably the most important factor in all of these approaches is personalisation. These approaches to care are enhanced through life-history work (i.e. when a healthcare professional has taken the time to get to know the person living with dementia and understands their personality). The final point to note is that note that these approaches are important, not only in reducing episodes of distress, but actually enhancing the wellbeing of people living with dementia.

Possible Questions for Consideration:

What other examples of non-pharmacological approaches have benefited people living with dementia?

What is the difference between validating someone’s reality and telling lies in dementia care?

What is actually needed to utilise garden therapy effectively?

What are the ethical issues associated with doll therapy?

When the approaches described do not reduce distress is it always appropriate to seek anti-psychotic medication?

Is there a difference between distress and challenging behaviour?


James I, Mackenzie L, Pakrasi S et al (2008a) ‘Non-pharmacological treatments of challenging behaviour’. Nursing Residential Care 10, (5), pp. 228-32

National Institute for Clinical Excellence (2011) A NICE–SCIE Guideline on supporting people with dementia and their carers in health and social care. National Clinical Practice Guideline Number 42. HMSO: London

Sink, K., Holden, F. and Yaffe, K. (2005) ‘Pharmacological treatment of neuropsyciatirc symptoms of dementia: A review of the evidence’, Journal of American Medical Association, 293, (5), pp. 596-608.

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  • Michael Horvich

    Thank you josmith for posting this. Yes, dealing with distress is an important part of being a caregiver for my partner who was diagnosed with Young Onset Alzheimer’s 11+ years ago when he was 55 years old. We are a same-sex couple who have been in our committed loving relationship for 40+ years.

    In our case a very, very low level of Risperidone has helped keep Gregory calm but NOT sedated and still engaged and very present. Because of his severe loss of language and processing ability, he is often unable to evaluate experiences (whether new, uncomfortable, or excessively loud) as safe or if he should be frightened and therefore combative. The drug has given him an overall “peace of mind” and I am grateful for this. The medical staff at his place are very sensitive to using drugs, are very careful in their decisions, and always include family in the decision making.

    We also do a lot of the ADLs (Activities of Daily Living) similar to those you talk about and they help provide a meaningful day for him. He has been at a memory care facility for 18 months now, has a private care day man with him to help with the activities as well as my help when I am there. He loves his music, his “walks” in the wheelchair, his exercises, being read aloud to, snacks, DVDs, story telling of his past (I now tell his stories and my own.) ETC

    I read about your blog in a post from Kate Saffer and am posting my reply to her about your article.

    Thanks for being there josmith!

    In my comments to Kate Swaffer on her blog and in our backs and forths replying, I am becoming more aware of dementia in terms of thoughts, opinions, and attitudes of those who have it and those who do not. I have become more sensitive but still hold strongly to some of my previous views.

    So based on the recent post of Kate’s based on your post (josmith,) on things that can be done to help people with dementia in a better place, especially when distressed, agitated or upset, in place of using drugs, I made these comments.

    You can read Kate’s full post here:

    If the activities help, in place of drugs, great. You are right to wonder about calling them “interventions” as they are the daily activities of life just used more purposefully.

    Many of the activities are good for residential as well as people who are still in the community. They are “just things people do” so why not do them wherever and whenever needed?

    I am a person without dementia and I put on my headphones and listen to music when I need to calm my nerves or control my periodic depression. I take walks to help me think. I pet my cat, play fetch (she actually returns the puff ball to my hand,) laugh when she climbs circus style to the top of a ten foot ladder, and cry into her fur when sad.

    These are my DLA’s so why shouldn’t they be Gregory’s. My theory is (and it is not original) “Whatever works, works. That is the measure of doing it or not!”

    Gerry, who has advanced dementia, loves her doll, talks to it, protects it, and shushes us when it is sleeping. It keeps her happy and feeling useful. What is the matter with playing with dolls if it works.

    Vivian. who is less advanced than Gerry, says, “That is so foolish to play with dolls. My children are grown and I don’t have to baby them anymore. I’d rather eat ice cream to keep me happy.” What is the matter with eating ice cream and gaining a few pounds if it works. Also in small amounts and if monitored will it really hurt a diabetic?

    Gregory has a Teddy Bear because I felt a “doll” would not “speak” to him but wanted him to have something like a “blankie” to comfort him. It works! He has always loved Teddy Bears. He loves this one who we have pegged, “Peaceful the Bear.”

    He holds it for comfort, throws it down when he is upset. He cries into it when listening to emotional classical music and he fondles its soft fur absent-mindedly.

    The bear has become a mascot for many of the residents and most of the staff at Gregory’s memory care facility.

    I have three more identical ones in the closet in case one goes missing or falls apart. I laughingly tell myself that I am a good mother. And if that works why not do it!

    * * *

    On a separate note, I am thinking about some recent facebook issues and comments that should be shared but value judgement left behind.”

    It reminds me of when homosexuality in the 70’s and 80’s was just beginning to organize itself, become more visible, fight for justice, come out! The Gay Men and the Lesbians more often than not bumped heads and battled when it came to labels like Gay and did that or did that not include Lesbians? And who is speaking for whom and why!

    Now we are GLBTQ and very visible (including more and more same sex marriage support world wide) So call it what you want Gay, Lesbian, Bi-Sexual, Transgender, and/or Questioning … we have come together.

    The current (for lack of better words) battle between those with dementia and those without dementia, between those diagnosed and those who give care might just be leading us to a better place. Since reading much of your work and having done other research, I find I am being more careful with my vocabulary and realizing that some of my views are arguable and even insulting to some.

    I just recently (on waking in the middle of the night) revisited one of my blogs to clean it up. It came on too strong and for people who do not know me could very well wreak havoc in opinions. So I was comfortable to scale my comments back enough to still get the message across but not to offend anyone or open wounds or create new ones (especially for me:-)

    The blog I changed was:

    My general blog address is: