Nonpharmacological Interventions for Aggressive Behaviors in Dementia

Thursday, July 10 2025 Nonpharmacological Interventions for Aggressive Behaviors in Dementia

Under recently revised CMS guidance for nursing homes, F605 imposes new requirements for nursing home staff who are managing aggressive behaviors in residents. In order to reduce unnecessary psychotropic medications, nonpharmacological interventions are the first-line treatment.

Aggressive behavior is a type of agitation “consisting of overt harmful actions (physical or verbal) that are clearly not accidental,” explains the Agency for Healthcare Research and Quality. One of several reasons for the persistence of psychotropic drug usage in managing aggression is that caregivers are not well equipped with alternative strategies for managing these dangerous situations, they add.

Some approaches that can help are: understanding triggers, using sensory practices, using validation therapy, and applying the DICE model. Here’s a closer look.

Understand triggers

For any resident who is experiencing BPSDs, it is helpful to observe triggers, such as social and environmental factors. There are many behavioral challenges that can be side-stepped simply by recognizing what a resident needs.

Physical triggers can be pain, hunger, difficulty breathing, constipation, or other discomfort that may be hard to express. In the environment, factors such as noise levels, lighting, other people, or temperature can trigger distress, explains the GuideStar blog about redirecting behaviors. Behaviors such as aggression can be a response to an unmet need. As a best practice to help prevent BPSDs, Scales et al. recommend simplifying the environment, making it “free from clutter and distractions, using visual cues for orientation”.

How you communicate with a resident can also have a big impact. Stay calm, and pay attention to your body language, approach, and communication techniques. Eye contact and a positive mood can help a resident, notes the GuideStar blog.

An individual behavior log can incorporate specific descriptions of a resident's behaviors, timing, and underlying circumstances to help you build an understanding. Getting to know the resident and aiming to identify unmet needs are essential to honoring dignity and personhood.

Sensory practices

Sensory practices recognize that people living with dementia may be “particularly vulnerable to sensory deficits,” according to Scales et al. This “can reduce their capacity to interpret and manage the demands of their environment.” Sensory practices may help correct sensory imbalances and reduce agitation, they say.

A promising strategy is massage. “A small evidence base shows positive results for the effectiveness of massage in helping reduce agitation, aggression, stress, anxiety, depression, and disruptive vocalizations in the immediate or short term,” they note. Activating the sense of touch, creating a social connection, and triggering a physiological response may all play into the value of massage. Calm-inducing aromatic oils (e.g., lavender, lemon balm) incorporated into hand cream or massage cream also seem to be effective.

Multi-sensory stimulation (MSS), exemplified by the Snoezelen model, stimulates “multiple senses through a combination of light effects, calming sounds, smells, and/or tactile stimulation,” say Scales et al. MSS shows promise for managing aggression. Without a Snoezelen room, a practical application of this idea is to work MSS concepts into daily care routines. Just look for ways to engage several senses at once within a calm, gently lit environment. For example, you can use calming music along with aromatherapy-infused shoulder massage. Some caregivers offer something soft to hold and handle.

Validation therapy

Validation therapy wholly accepts the reality a resident is experiencing (without trying to correct it). Through empathy and communication techniques, “the aim of validation therapy is to alleviate negative feelings and enhance positive feelings,” explain Scales et al. Communication techniques incorporate “using nonthreatening words to establish understanding; rephrasing the person’s words; maintaining eye contact and a gentle tone of voice; responding in general terms when meanings are unclear; and using touch if appropriate,” they explain.

To use these techniques, you can start by giving the person your full attention and listening carefully. Then respond without judgment and with empathy, e.g., “You are feeling angry right now.” You can validate what someone is experiencing with a statement like, “I see that the loud TV next door is making it hard for you to listen to your music. That sounds really frustrating.”

DICE

DICE was designed to equip caregivers with solutions to challenging behaviors in dementia care. An acronym, DICE stands for:

Describe: Observe the details of the situation; define the frequency and severity.
Investigate: Look for contributing factors such as medical or environmental factors.
Create: Create a person-centered care plan.
Evaluate: Assess and modify the plan as needed.

Here is an example. Consider Mrs. R., who is yelling and throwing food during mealtime.

Describe, with a focus on what, when, where, and how: Mrs. R. threw her food tray, yelling “I want to go home,” appearing agitated and flushed, with clenched hands. This occurred during dinner in the dining room. It appeared as a sudden outburst.
Investigate: Consider medical causes—Is she in pain? Is she having constipation? Is any medication timing or dosing impacting her? Is she having difficulty feeding herself or eating? Is she tired and trying to eat too late in the day? How is the environment? Is it loud? Too hot or too cold? Consider her personal history—Did she enjoy large family dinners in her own home? What were her mealtime routines like before? Does she prefer specific foods or textures? Does she want something that’s not here? What does “I want to go home” truly mean for her? It could be a desire for security, familiarity, or something else she can’t articulate. Also consider how staff are interacting with her during meals. Was someone approaching her from behind? Or behaving abruptly? Were there clear, simple cues given?
Create: You can validate her feelings and reassure her: “It sounds like you’re feeling unsettled. We want you to feel safe and comfortable here.” Based on your investigation, a plan you create might include addressing physical discomfort, offering a preferred comfort food or beverage in a calmer setting (e.g., small table or her room). Offer her a choice. In a more secure setting, you can play calming background music and use soft lighting. If you believe timing was a factor, you might shift her mealtime earlier by an hour. You might offer her a light shoulder massage before the meal begins. You can ensure that staff are using a calm, reassuring tone and an unhurried approach. You can communicate and document to help make the specific plan you create consistent across shifts.
Evaluate: Monitor her behavior during subsequent mealtimes. How is the plan working? Is the frequency and intensity of outbursts decreasing? Is she eating better? Document what you observe. If the behavior continues or worsens, look for new clues and revise the plan.

Implementing DICE can be an iterative process. A person-centered approach, patience, and a calm mindset can help make it successful. Staff collaboration and communication are essential. Be sure to document observations, interventions, and monitoring as you go along.