Psychological Interventions

As described earlier in this chapter and only for ease of explanation, we opted to include in this group of psychological interventions three main approaches: behavior oriented, emotion oriented, and sensory stimulation oriented. Although sharing the same goal - to promote the best possible quality of life for patients and their caregivers - they use different techniques to address specific needs and symptoms.

Behavior-Oriented Approaches

Behavior-oriented interventions are mainly focused on the control and the reduction of the frequency of behavioral symptoms.

Knowing the role that psychological processes play in behavioral symptoms, these interventions are based on three main theoretical models: (1) conditioned learning principles, which explain that behaviors tend to be reinforced if they are associated to some kind of gains [31]; (2) the unmet needs theory, which explains that some behaviors result from normal human social and individual needs that are not being expressed or identified and therefore adequately fulfilled [8]; and (3) the environmental vulnerability stress threshold model, which explains inappropriate behavior as a consequence of the reduced capacity of patients with dementia to cope with stress. Cognitive deficits resulting from dementia difficult the perception and comprehension of internal and external needs. Factors such as fatigue, multiple competing stimuli, physical conditions, and changes in caregivers or environment might increase the level of stress as they can be felt as demands that exceed the patient’s individual abilities [32].

These interventions are mainly developed to deal with the most frequent inappropriate or distress behaviors associated with dementia such as agitation (with and without aggressive behaviors), wandering, and sleep disturbances, and they aim to identify causes and trigger factors that might induce behavioral problems and to reduce them through environment changes.

This group of interventions can use different sets of techniques, varying from patient-oriented - such as sensory and social contact (real or simulated), behavior therapy, and structured activities - to caregiver-targeted interventions such as staff training [33] or individual work with the family [34]. Staff and informal caregivers are trained to prevent symptoms from emerging or to reduce their frequency and severity by adapting communication skills to improve the interaction with patients. As recommended [35 ] , caregivers should aim to encourage socially appropriate behaviors, to involve patients in meaningful activities and social interactions, and to control and balance levels of stimulation. Helping caregivers to understand how different factors can contribute to a specific behavior, the way these symptoms can be assessed and mapped, and how to control some trigger distress factors can successfully lead to the reduction of the frequency of disrupted behaviors. For example, habit training such as bedtime or hygiene routines might be effective on reducing sleep disturbances and frequent urinary incontinence [3, 9].

In the same way, physical environment can also be the target of intervention by removing physical restraints (e.g., remove doors, avoid floor levels and color/pat- tern differences) and objects that could be misinterpreted (e.g., dubious paintings) or providing adequate lightening and references for spatial orientation (e.g., tape on floor, signs, and labels).

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