The Tailored Activity Program to Reduce Behavioral Symptoms in Individuals With Dementia: Feasibility, Acceptability, and Replication Potential

Behavioral symptoms such as resistance to care, shadowing, vocalizations, or physical aggression are common in the 5.2 million individuals living with dementia in the United States (Alzheimer's Association, 2008). Behaviors profoundly affect individuals with dementia and their families, compromising their quality of life and safety, heightening caregiver burden and risk for nursing home placement, and increasing health care costs (Ballard, Lowery, Powell, O’Brien, & James, 2000). Even passive behaviors (withdrawal, apathy) are sources of frustration and sadness to families (Colling, 2004). Behaviors occur across the disease trajectory and dementia types and cannot be attributed to cognitive impairment alone. Emerging conceptual frameworks for understanding behavioral symptoms suggest that behaviors are an outcome of the interaction of individuals and their environments and should be addressed using nonpharmacological approaches. For example, the need-driven dementia-compromised behavior approach views behavior as an expression of an internal or unmet need in the person's environment that can be identified and addressed (Fitzsimmons & Buettner, 2002); the progressively lowered stress threshold views behavior as a response in part to the buildup of environmental stressors that overwhelm the capacity of the individual with dementia (Hall & Buckwalter, 1987); and the Antecedent–Behavior–Consequences approach targets specific triggers prior to and following a behavioral occurrence (Volicer & Hurley, 2003). Finally, the competence–environmental press model (Lawton & Nahemow, 1973) suggests that there are optimal combinations of environmental circumstances or conditions, and personal competencies that result in the highest possible functioning for individuals with compromised cognitive functioning. Obtaining the just-right fit between individual capabilities and external environmental demands results in adaptive positive behaviors; alternately, environments that are too demanding or understimulating result in behavioral symptoms such as agitation or passivity in individuals with dementia. Developing, testing, and translating nonpharmacological approaches to manage disruptive behavioral symptoms are important public health priorities for advancing better care of individuals with dementia (American Psychiatric Association Work Group, 2007; Cohen-Mansfield, 2001, 2005; Lyketsos et al., 2006; Salzman et al., 2008). The focus on nonpharmacological approaches is warranted in light of recent research showing that pharmacological solutions are not available for some of the most distressful behaviors (e.g., wandering, repetitive questioning, shadowing), have only modest benefits, and can pose considerable risk. The latter is particularly the case for the off-label use of atypical antipsychotic drugs commonly used for behavioral symptoms, which now have a Food and Drug Administration black box warning of increased mortality risk among older adults with dementia (Ballard et al., 2009; Salzman et al., 2008; Schneider et al., 2006; Selbaek, Kirkevold, & Engedal, 2007; Sink, Holden, & Yaffee, 2005).