Intended for healthcare professionals

Rapid response to:


Sensory stimulation in dementia

BMJ 2002; 325 doi: (Published 07 December 2002) Cite this as: BMJ 2002;325:1312

Rapid Response:

Behavioural and Psychological Symptoms of Dementia (BPSD) . The issue is the cause not the cure

The authors are to be commended both for writing frankly about
inappropriate use of neuroleptics with BPSD, and equally, about the low
quality of much of the psychosocial literature, where enthusiastic
assertions uncontaminated by evidence remain sadly common. Indeed Burns,
Byrne, Ballard, and Holmes have been amongst an increasing number of
researchers who are pro-active in developing methodologies to test the
effectiveness of non-drug approaches to BPSD.

We suggest that a conceptual problem remains. We agree that it is
important to scientifically evaluate the effectiveness of particular
approaches that can become part of the clinician’s tool-kit, for example
‘white noise’ through headphones for disruptive vocalisations.1 However,
we believe that it is a mistake analogous to the reflex prescribing of
neuroleptics, (though with less risk of side effects), to reach for a
psychosocial cure before assessing the cause – or usually multiple causes
- of the behaviour. This goes beyond the essential screening for
physiological aetiology such as infections, pain, or drug interactions,
that are alluded to by the authors.

For example, we know that the most common cause of sleep disturbance
in nursing homes is because staff wake patients up. 2 It would be
remarkably shortsighted to commence bright-light therapy for sleep
disturbance without having first assessed the behaviour of night staff. We
know that most incidents of aggression are not random but occur in
personal care.3 It would be naive to apply some standard psychosocial
therapy to the patient without first having observed how personal care is
carried out and, if necessary, helped staff adjust it. 4 We even know that
what causes behaviour in dementia to become ‘challenging’, and thus
attract the label BPSD, is idiosyncratic to the individual carer or nurse,
or the individual nursing home.5,6, A major problem for one person or one
nursing home is not a problem elsewhere. So long as the behaviour does
not put the patient or others at risk, and/or is not an expression of
distress by the patient, it would be irresponsible to apply a standard
therapy to the patient when the problem can be alleviated by the carer or
nursing staff support and perception change.

That is, behaviour in this vulnerable population which causes
problems for carers or nursing staff needs careful diagnostic work-up,
investigating both physiological and psychosocial causes of the
behaviour, and also what has caused it to become a problem in the first
place. Interventions should be applied based upon this analysis, 4 rather
than applying a standard method such as aromatherapy. Indeed in the
clinical situation complementary therapy such as aromatherapy and massage
can have no effect, positive effect or even a negative effect, depending
on the individual, the staff or the nursing home. 7 An intervention may
well involve one of these methods and this is why it is important to
devise methodology to assess whether they are effective. However, in a
recent controlled trial 6, the most common interventions were changing the
behaviour of carers or nursing staff, and providing them with emotional
support and education. The same study showed that a careful work up of the
case and then designing psychosocial and/or pharmacological interventions
to fit its idiosyncrasies was more effective than a control group where
medication was, almost exclusively, the front-line treatment. It took less
time overall, produced far few drug side effects, and enabled all patients
to be managed in place.

Thus we return to reiterate the main point of the editorial by Burns,
Byrne, Ballard, and Holmes. Whatever the reason for reflex recourse to the
prescription pad for BPSD, it is certainly not because there are no
effective alternatives.


1.Burgio L, Scilley K, Hardin J, Hsu, C, Yancey J. Environmental
‘white noise’: an intervention for verbally agitated nursing home
residents. Journals of Gerontology, Psychological Sciences 1996; 51B: P364

2. Schnelle J, Ouslander, J, Simmons, S, Alessi C., Gravel, M. The
night-time environment, incontinence care, and sleep disruption in nursing
homes. Journal of the American Geriatrics Society 1993; 41: 286-294.

3. Bridges-Parlet S, Knopman D, Thompson T. A descriptive study of
physically aggressive behvaiour in dementia by direct observation. Journal
of the American Geriatrics Society 1994; 42: 192-197.

4. Moniz-Cook, E.D., Stokes, G. Agar, S. (in press). Difficult
Behaviour and Dementia in Nursing Homes: Five cases of Psychosocial
Intervention. Journal of Clinical Psychology & Psychotherapy

5. Moniz-Cook E, Woods R, Gardiner E. Staff factors associated with
perception of behaviour as ‘challenging’ in residential and nursing homes.
Aging and Mental Health 2000; 4: 48-55.

6. 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 2001, Canberra,

7. Brooker, D. J. R., Snape, M., Johnson, E., Ward, D. Payne, M.
(1997). Single case evaluation of the effects of aromatherapy and massage
on disturbed behaviour in severe dementia. British Journal of Clinical
Psychology, 36, 287-296.

Competing interests:  
None declared

Competing interests: No competing interests

11 December 2002
Esme D Moniz-Cook
Senior Cinical Lecturer/Consultant Clinical Psychologist
Mike Bird , Australian National University/NSW Southern Area Mental Health Service, Australia
Coltman Street Day Hospital HU3 2SG